Guest guest Posted March 17, 2006 Report Share Posted March 17, 2006 Kathy,As a parent, I recognize this "testing limits" behavior and I think you get the same results in children as in drug-seeking adults. If you don't keep your word, they know they don't have to keep theirs. I would say, "I'm sorry, but you and I both agreed to these conditions. If you can't abide by the terms then I cannot prescribe narcotics for you." It's the tough love approach. If you give in this one time, next time it will be pills accidentally dropped in the toilet, or left at her cousin's house in Texas, or aliens abducted her pills, etc. Also, Darvocet is not recommended for treatment of chronic pain: http://www.wisc.edu/trc/projects/pop/DrugSpecific.html. Perhaps she should try Cymbalta, a new anti-depressant which can help with the pain of fibromyalgia: http://www.medicalnewstoday.com/medicalnews.php?newsid=15180If you want to give her a chance, you could say, "If you get back on your antidepressant, sign up for yoga, and honor the terms of the contract, then I will refill your pain pills at the time they would've been refilled." It's tough, but you can't save everyone. Good luck!(No financial interests in Cymbalta) SetoSouth Pasadena, CA I have a question about how others handle difficult patients and drug seeking patients. I know that Pamela has commented on this some. I have a specific difficult patient in mind who is coming in to see me tomorrow. How hard nosed should I be, and when does one go from treating the individual and giving many second chances, to being a push over? What techniques do others use in similar situations? I am not sure if discussing particular patients is appropriate for this forum but this patient is representative of many other similar patients with similar problems. This is a chronic pain patient who has been fired from several other clinics, due to not following through on drug contracts, but also has traumatic brain injury with short term memory loss and depression. She has had a very thorough workup of her pain to date, with no obvious cause other than probable myofascial pain. I agreed to see her and prescribe darvocet, which I don't like much as a pain medication,if she would sign a medication contract which included language about no replacements if she loses medicine, dealing with the pain medication on visits only, and if she needed to contact me, on one specific day of the week only, and never after hours for the pain, following through on my recommendations, ... If she didn't abide by the agreement then I could dismiss her from the practice. She is also a medicaid patient and has been placed on a lockin program so that she can only see one doctor, go to one pharmacy, and one hospital. She did pretty well for the first month,pain wise, but hadn't followed any other of my recommendations. Then she decided to stop her antidepressant and go without all medication, except for her pain medication for her chronic pain of course. I told her that I would agree to that as long as she tried something else, such as yoga, Tai Chi, or acupuncture. Which I have been talking about since she first started coming. She came into the office 2 days later without an appointment when I was out of the office, paged me to talk with me, told me that she thought her medication had been stolen and the pain was too much for her. I told her I would only talk about it in the office and she is coming in tomorrow, but it has ruined the rest of the day, as I just worrying about it. She still hadn't tried anything else that I have recommended to help decrease her perception of pain. So here she has violated several things on the contract already, but most likely because she is withdrawing from her antidepressant which she went off cold turkey on her own and recurrence of the depression. I agreed to see her tomorrow and I am torn about whether to not give her any more medication, to just go ahead and dismiss her, or to require that she restart her antidepressant, give her enough medication til her next refill next week. If I don't follow through on the contract, I am just a push over or am I being sympathetic. , I figure that one way or another, if she violates anything further on the contract after this visit that I will dismiss her. I usually end up being a pushover and I don't know if it is because I don't want confrontation or what. I hate spending all this time worrying about this. Kathy Broman Mason City, IA kmlb2@... Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 17, 2006 Report Share Posted March 17, 2006 I agree with you, Annie. It is a huge task for one physician who also has to feed her own family and keep some positive energy for her children. I tried with several patients but you just can's 'save their soul', put yourself in a malpractice situation, come back home a bundle of worries and manage your other patients. And, you know, there should be also an individual responsibility to their life. > > Hi Kathy, > In a previous life I had the opportunity to work with long term > mentally ill adults in a community based social work program.  The > sort of person you describe needs more than an individual family > doctor can provide. Unfortunately, few communities have the sort of > comprehensive program that can really meet those needs, and even those > that do can’t keep all these folks out of trouble. >  > People with the problems your patient has live chaotic, disorganized > lives and have problems at every level. The very best thing for them > is a social support program that includes a supervised social setting > (the one I worked at was a “club†with a soda bar and pool tables, > other games, books and magazines, etc that was “staffed†by patients > (but we didn’t call them that), regular home visits by case workers to > help with banking, paying bills, making sure they don’t get credit > cards or shop on QVC, “life skill†programs on > nutrition/shopping/cooking (and help dumping all the rotten stuff > every couple months)…and so much more I can’t even name it all. The > family doctor’s (or psychiatrist’s) roll in this situation is VERY > LIMITED, and personally I think it should stay that way.  As a > society, we can’t afford to pay to train MDs and then have them doing > home visits to go thru the mail.   Of course we can’t really afford > to keep all these folks in jail when they end up there, and if they > don’t run afoul of the law our mandate to maintain them in “the least > restrictive environment†means we do a piss-poor job of helping them. >  But that is NOT a problem you can solve, even for one patient. >  > The very best thing you could do is hook this lady up with a program > that CAN help her keep her life together.  If you can get a > relationship with her case worker, that person could be recruited to > function as a “gate-keeper†for you (they do it for the psychiatrists > all the time) The very best thing you can do for yourself is SET THE > LIMITS AND STICK TO THEM.  As hard as it is, you must be willing to > let her hang herself (figuratively speaking of course) if that is what > she insists on doing. Show her where the edge of the cliff is, and if > she still walks off….gravity treats the good, the bad and the just > plain dumb all the same. There is no value in you feeling guilty > about that. >  > Just my take on it, > Annie >  > Difficult patients >  > > I have a question about how others handle difficult patients and drug > seeking patients. I know that Pamela has commented on this some. I > have a specific difficult patient in mind who is coming in to see me > tomorrow. How hard nosed should I be, and when does one go from > treating the individual and giving many second chances, to being a push > over? What techniques do others use in similar situations? I am not > sure if discussing particular patients is appropriate for this forum > but this patient is representative of many other similar patients with > similar problems. > This is a chronic pain patient who has been fired from several other > clinics, due to not following through on drug contracts, but also has > traumatic brain injury with short term memory loss and depression. She > has had a very thorough workup of her pain to date, with no obvious > cause other than probable myofascial pain. I agreed to see her and > prescribe darvocet, which I don't like much as a pain medication,if she > would sign a medication contract which included language about no > replacements if she loses medicine, dealing with the pain medication on > visits only, and if she needed to contact me, on one specific day of > the week only, and never after hours for the pain, following through on > my recommendations, ... If she didn't abide by the agreement then I > could dismiss her from the practice. She is also a medicaid patient > and has been placed on a lockin program so that she can only see one > doctor, go to one pharmacy, and one hospital. > She did pretty well for the first month,pain wise, but hadn't followed > any other of my recommendations.  Then she decided to stop her > antidepressant and go without all medication, except for her pain > medication for her chronic pain of course. I told her that I would > agree to that as long as she tried something else, such as yoga, Tai > Chi, or acupuncture. Which I have been talking about since she first > started coming. She came into the office 2 days later without an > appointment when I was out of the office, paged me to talk with me, > told me that she thought her medication had been stolen and the pain > was too much for her. I told her I would only talk about it in the > office and she is coming in tomorrow, but it has ruined the rest of the > day, as I just worrying about it. She still hadn't tried anything else > that I have recommended to help decrease her perception of pain. > So here she has violated several things on the contract already, but > most likely because she is withdrawing from her antidepressant which > she went off cold turkey on her own and recurrence of the depression. > I agreed to see her tomorrow and I am torn about whether to not give > her any more medication, to just go ahead and dismiss her, or to > require that she restart her antidepressant, give her enough medication > til her next refill next week. If I don't follow through on the > contract, I am just a push over or am I being sympathetic.  , I > figure that one way or another, if she violates anything further on the > contract after this visit that I will dismiss her. I usually end up > being a pushover and I don't know if it is because I don't want > confrontation or what. I hate spending all this time worrying about > this. >      > > Kathy Broman > Mason City, IA > kmlb2@... > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 17, 2006 Report Share Posted March 17, 2006 Speaking of Darvocet, there are really no opioids that are technically “recommended” for chronic pain. Opioids are arguably only truly indicated long term in malignancy pain, though we tend to forget that when we see how pain doctors use these meds. I’ve actually seen some attorney ads looking for class action patients if they have been on Oxycontin for more than 6 mos for non-cancer pain. So, I’m not sure Darvocet is any different in & of itself. Cymbalta MAY be worth a try, unless the pt s a seeker. Re: Difficult patients Kathy, As a parent, I recognize this " testing limits " behavior and I think you get the same results in children as in drug-seeking adults. If you don't keep your word, they know they don't have to keep theirs. I would say, " I'm sorry, but you and I both agreed to these conditions. If you can't abide by the terms then I cannot prescribe narcotics for you. " It's the tough love approach. If you give in this one time, next time it will be pills accidentally dropped in the toilet, or left at her cousin's house in Texas, or aliens abducted her pills, etc. Also, Darvocet is not recommended for treatment of chronic pain: http://www.wisc.edu/trc/projects/pop/DrugSpecific.html. Perhaps she should try Cymbalta, a new anti-depressant which can help with the pain of fibromyalgia: http://www.medicalnewstoday.com/medicalnews.php?newsid=15180 If you want to give her a chance, you could say, " If you get back on your antidepressant, sign up for yoga, and honor the terms of the contract, then I will refill your pain pills at the time they would've been refilled. " It's tough, but you can't save everyone. Good luck! (No financial interests in Cymbalta) Seto South Pasadena, CA I have a question about how others handle difficult patients and drug seeking patients. I know that Pamela has commented on this some. I have a specific difficult patient in mind who is coming in to see me tomorrow. How hard nosed should I be, and when does one go from treating the individual and giving many second chances, to being a push over? What techniques do others use in similar situations? I am not sure if discussing particular patients is appropriate for this forum but this patient is representative of many other similar patients with similar problems. This is a chronic pain patient who has been fired from several other clinics, due to not following through on drug contracts, but also has traumatic brain injury with short term memory loss and depression. She has had a very thorough workup of her pain to date, with no obvious cause other than probable myofascial pain. I agreed to see her and prescribe darvocet, which I don't like much as a pain medication,if she would sign a medication contract which included language about no replacements if she loses medicine, dealing with the pain medication on visits only, and if she needed to contact me, on one specific day of the week only, and never after hours for the pain, following through on my recommendations, ... If she didn't abide by the agreement then I could dismiss her from the practice. She is also a medicaid patient and has been placed on a lockin program so that she can only see one doctor, go to one pharmacy, and one hospital. She did pretty well for the first month,pain wise, but hadn't followed any other of my recommendations. Then she decided to stop her antidepressant and go without all medication, except for her pain medication for her chronic pain of course. I told her that I would agree to that as long as she tried something else, such as yoga, Tai Chi, or acupuncture. Which I have been talking about since she first started coming. She came into the office 2 days later without an appointment when I was out of the office, paged me to talk with me, told me that she thought her medication had been stolen and the pain was too much for her. I told her I would only talk about it in the office and she is coming in tomorrow, but it has ruined the rest of the day, as I just worrying about it. She still hadn't tried anything else that I have recommended to help decrease her perception of pain. So here she has violated several things on the contract already, but most likely because she is withdrawing from her antidepressant which she went off cold turkey on her own and recurrence of the depression. I agreed to see her tomorrow and I am torn about whether to not give her any more medication, to just go ahead and dismiss her, or to require that she restart her antidepressant, give her enough medication til her next refill next week. If I don't follow through on the contract, I am just a push over or am I being sympathetic. , I figure that one way or another, if she violates anything further on the contract after this visit that I will dismiss her. I usually end up being a pushover and I don't know if it is because I don't want confrontation or what. I hate spending all this time worrying about this. Kathy Broman Mason City, IA kmlb2@... Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 17, 2006 Report Share Posted March 17, 2006 When a doctor is new in practice I think that they get an excess of dug seekers. I made it a policy not to prescribe more than 10 days of narcotics to anyone except my long time patients from my previous practice and even then only to people who have a medical diagnosis causing the pain. I have had numerous new patients come in for narcotics for this or that and I kindly tell them that I never prescribe narcotics and give them their co-pay back. I usually never see them again. For my long time patient's who lose their prescriptions I tell them sorry I can't refill their prescription until the next one is due and ask them to be more careful in the future. I take care of a lot of people with ADD. They really could be losing their stimulant prescriptions due to their inattention but I still don't refill their prescription early. Years ago when I wasn't as careful I had a patient who got their prescription just a few days early each month and sold the rest. I worked with someone whose 70 year old grandmother was selling her narcotics to get a little extra cash.Larry Lindeman MD I have a question about how others handle difficult patients and drug seeking patients. I know that Pamela has commented on this some. I have a specific difficult patient in mind who is coming in to see me tomorrow. How hard nosed should I be, and when does one go from treating the individual and giving many second chances, to being a push over? What techniques do others use in similar situations? I am not sure if discussing particular patients is appropriate for this forum but this patient is representative of many other similar patients with similar problems. This is a chronic pain patient who has been fired from several other clinics, due to not following through on drug contracts, but also has traumatic brain injury with short term memory loss and depression. She has had a very thorough workup of her pain to date, with no obvious cause other than probable myofascial pain. I agreed to see her and prescribe darvocet, which I don't like much as a pain medication,if she would sign a medication contract which included language about no replacements if she loses medicine, dealing with the pain medication on visits only, and if she needed to contact me, on one specific day of the week only, and never after hours for the pain, following through on my recommendations, ... If she didn't abide by the agreement then I could dismiss her from the practice. She is also a medicaid patient and has been placed on a lockin program so that she can only see one doctor, go to one pharmacy, and one hospital. She did pretty well for the first month,pain wise, but hadn't followed any other of my recommendations. Then she decided to stop her antidepressant and go without all medication, except for her pain medication for her chronic pain of course. I told her that I would agree to that as long as she tried something else, such as yoga, Tai Chi, or acupuncture. Which I have been talking about since she first started coming. She came into the office 2 days later without an appointment when I was out of the office, paged me to talk with me, told me that she thought her medication had been stolen and the pain was too much for her. I told her I would only talk about it in the office and she is coming in tomorrow, but it has ruined the rest of the day, as I just worrying about it. She still hadn't tried anything else that I have recommended to help decrease her perception of pain. So here she has violated several things on the contract already, but most likely because she is withdrawing from her antidepressant which she went off cold turkey on her own and recurrence of the depression. I agreed to see her tomorrow and I am torn about whether to not give her any more medication, to just go ahead and dismiss her, or to require that she restart her antidepressant, give her enough medication til her next refill next week. If I don't follow through on the contract, I am just a push over or am I being sympathetic. , I figure that one way or another, if she violates anything further on the contract after this visit that I will dismiss her. I usually end up being a pushover and I don't know if it is because I don't want confrontation or what. I hate spending all this time worrying about this. Kathy Broman Mason City, IA kmlb2@... Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 17, 2006 Report Share Posted March 17, 2006 Refer those patients to a pain specialist and consider not taking them on and/or dismissal. Re: Difficult patients When a doctor is new in practice I think that they get an excess of dug seekers. I made it a policy not to prescribe more than 10 days of narcotics to anyone except my long time patients from my previous practice and even then only to people who have a medical diagnosis causing the pain. I have had numerous new patients come in for narcotics for this or that and I kindly tell them that I never prescribe narcotics and give them their co-pay back. I usually never see them again. For my long time patient's who lose their prescriptions I tell them sorry I can't refill their prescription until the next one is due and ask them to be more careful in the future. I take care of a lot of people with ADD. They really could be losing their stimulant prescriptions due to their inattention but I still don't refill their prescription early. Years ago when I wasn't as careful I had a patient who got their prescription just a few days early each month and sold the rest. I worked with someone whose 70 year old grandmother was selling her narcotics to get a little extra cash. Larry Lindeman MD I have a question about how others handle difficult patients and drug seeking patients. I know that Pamela has commented on this some. I have a specific difficult patient in mind who is coming in to see me tomorrow. How hard nosed should I be, and when does one go from treating the individual and giving many second chances, to being a push over? What techniques do others use in similar situations? I am not sure if discussing particular patients is appropriate for this forum but this patient is representative of many other similar patients with similar problems. This is a chronic pain patient who has been fired from several other clinics, due to not following through on drug contracts, but also has traumatic brain injury with short term memory loss and depression. She has had a very thorough workup of her pain to date, with no obvious cause other than probable myofascial pain. I agreed to see her and prescribe darvocet, which I don't like much as a pain medication,if she would sign a medication contract which included language about no replacements if she loses medicine, dealing with the pain medication on visits only, and if she needed to contact me, on one specific day of the week only, and never after hours for the pain, following through on my recommendations, ... If she didn't abide by the agreement then I could dismiss her from the practice. She is also a medicaid patient and has been placed on a lockin program so that she can only see one doctor, go to one pharmacy, and one hospital. She did pretty well for the first month,pain wise, but hadn't followed any other of my recommendations. Then she decided to stop her antidepressant and go without all medication, except for her pain medication for her chronic pain of course. I told her that I would agree to that as long as she tried something else, such as yoga, Tai Chi, or acupuncture. Which I have been talking about since she first started coming. She came into the office 2 days later without an appointment when I was out of the office, paged me to talk with me, told me that she thought her medication had been stolen and the pain was too much for her. I told her I would only talk about it in the office and she is coming in tomorrow, but it has ruined the rest of the day, as I just worrying about it. She still hadn't tried anything else that I have recommended to help decrease her perception of pain. So here she has violated several things on the contract already, but most likely because she is withdrawing from her antidepressant which she went off cold turkey on her own and recurrence of the depression. I agreed to see her tomorrow and I am torn about whether to not give her any more medication, to just go ahead and dismiss her, or to require that she restart her antidepressant, give her enough medication til her next refill next week. If I don't follow through on the contract, I am just a push over or am I being sympathetic. , I figure that one way or another, if she violates anything further on the contract after this visit that I will dismiss her. I usually end up being a pushover and I don't know if it is because I don't want confrontation or what. I hate spending all this time worrying about this. Kathy Broman Mason City, IA kmlb2@... Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 17, 2006 Report Share Posted March 17, 2006 Medically, I think it's Darvocet's metabolites which collect and potentially may cause more problems. Other opiates are a bit " cleaner " without the metabolites. Tim > Speaking of Darvocet, there are really no opioids that are technically > " recommended " for chronic pain. Opioids are arguably only truly > indicated long term in malignancy pain, though we tend to forget that > when we see how pain doctors use these meds. I've actually seen some > attorney ads looking for class action patients if they have been on > Oxycontin for more than 6 mos for non-cancer pain. So, I'm not sure > Darvocet is any different in & of itself. Cymbalta MAY be worth a try, > unless the pt s a seeker. > > > > > > > > Re: Difficult patients > > > > Kathy, > > As a parent, I recognize this " testing limits " behavior and I think you > get the same results in children as in drug-seeking adults. If you don't > keep your word, they know they don't have to keep theirs. I would say, > " I'm sorry, but you and I both agreed to these conditions. If you can't > abide by the terms then I cannot prescribe narcotics for you. " It's the > tough love approach. If you give in this one time, next time it will be > pills accidentally dropped in the toilet, or left at her cousin's house > in Texas, or aliens abducted her pills, etc. > > > > Also, Darvocet is not recommended for treatment of chronic pain: > http://www.wisc.edu/trc/projects/pop/DrugSpecific.html. > > Perhaps she should try Cymbalta, a new anti-depressant which can help > with the pain of fibromyalgia: > http://www.medicalnewstoday.com/medicalnews.php?newsid=15180 > > > > If you want to give her a chance, you could say, " If you get back on > your antidepressant, sign up for yoga, and honor the terms of the > contract, then I will refill your pain pills at the time they would've > been refilled. " It's tough, but you can't save everyone. Good luck! > > > > (No financial interests in Cymbalta) > > > > Seto > > South Pasadena, CA > > > > > > > > > > I have a question about how others handle difficult patients and drug > seeking patients. I know that Pamela has commented on this some. I > have a specific difficult patient in mind who is coming in to see me > tomorrow. How hard nosed should I be, and when does one go from > treating the individual and giving many second chances, to being a push > over? What techniques do others use in similar situations? I am not > sure if discussing particular patients is appropriate for this forum > but this patient is representative of many other similar patients with > similar problems. > This is a chronic pain patient who has been fired from several other > clinics, due to not following through on drug contracts, but also has > traumatic brain injury with short term memory loss and depression. She > has had a very thorough workup of her pain to date, with no obvious > cause other than probable myofascial pain. I agreed to see her and > prescribe darvocet, which I don't like much as a pain medication,if she > would sign a medication contract which included language about no > replacements if she loses medicine, dealing with the pain medication on > visits only, and if she needed to contact me, on one specific day of > the week only, and never after hours for the pain, following through on > my recommendations, ... If she didn't abide by the agreement then I > could dismiss her from the practice. She is also a medicaid patient > and has been placed on a lockin program so that she can only see one > doctor, go to one pharmacy, and one hospital. > She did pretty well for the first month,pain wise, but hadn't followed > any other of my recommendations. Then she decided to stop her > antidepressant and go without all medication, except for her pain > medication for her chronic pain of course. I told her that I would > agree to that as long as she tried something else, such as yoga, Tai > Chi, or acupuncture. Which I have been talking about since she first > started coming. She came into the office 2 days later without an > appointment when I was out of the office, paged me to talk with me, > told me that she thought her medication had been stolen and the pain > was too much for her. I told her I would only talk about it in the > office and she is coming in tomorrow, but it has ruined the rest of the > day, as I just worrying about it. She still hadn't tried anything else > that I have recommended to help decrease her perception of pain. > So here she has violated several things on the contract already, but > most likely because she is withdrawing from her antidepressant which > she went off cold turkey on her own and recurrence of the depression. > I agreed to see her tomorrow and I am torn about whether to not give > her any more medication, to just go ahead and dismiss her, or to > require that she restart her antidepressant, give her enough medication > til her next refill next week. If I don't follow through on the > contract, I am just a push over or am I being sympathetic. , I > figure that one way or another, if she violates anything further on the > contract after this visit that I will dismiss her. I usually end up > being a pushover and I don't know if it is because I don't want > confrontation or what. I hate spending all this time worrying about > this. > > > Kathy Broman > Mason City, IA > kmlb2@... > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 17, 2006 Report Share Posted March 17, 2006 Another thought on this situation - with her traumatic brain injury you describe she sounds somewhat cognitively impaired. Could someone argue that she can't understand the risks and benefits of opiate treatment and thus is not capable of signing a contract or consenting for treatment? What I'm getting at is that it is risky continuing to prescribe controlled substances to a non-compliant patient with impaired cognition. If there is some bad outcome (she overdoses, she injures someone in a car accident, she leaves kids in a hot car, etc.) you can be sure that some attorney somewhere will trace back blame to you, the intelligent prescribing physician, who should have known better than to prescribe mind-altering drugs to a poor, impaired individual who doesn't know as much about medicine as you do. I know I'm playing devil's advocate in this but I have seen people get burned trying to bend over backwards to help a patient like this - unfortunately, when the sh- hits the fan, people always look for the deep pocket to assign responsibility. I think you can give patients like this a choice - treat the pain with non-narcotic medications (antidepressants - both for depression and neuropathic pain, e.g. low-dose tricyclic, and anti-convulsants, NSAID's, etc.), or give her 30-day notice to find another provider. One analogy I use with patient is this: If I feel someone in the office has appendicitis, I know that the right treatment is further workup, CT, U/S, surgery, etc., I would not continue to give narcotics or analgesics indefinitely if the patient did not follow-through on work-up. I tell patients that pain is a complex condition that needs appropriate treatment (like your recommendations for Tai-Chi, yoga, etc.), not just refills on pain meds. I have found that this analogy helps with some patients. I want to emphasize that I do use long term narcotics successfully with many chronic pain patients - I am not completely against it - you just have to be comfortable with the relationship and ensure that a patient's function is improved with the opiate. Good Luck! Rancho Mirage, CA --- Kathy Broman wrote: > I have a question about how others handle difficult > patients and drug > seeking patients. I know that Pamela has commented > on this some. I > have a specific difficult patient in mind who is > coming in to see me > tomorrow. How hard nosed should I be, and when does > one go from > treating the individual and giving many second > chances, to being a push > over? What techniques do others use in similar > situations? I am not > sure if discussing particular patients is > appropriate for this forum > but this patient is representative of many other > similar patients with > similar problems. > This is a chronic pain patient who has been fired > from several other > clinics, due to not following through on drug > contracts, but also has > traumatic brain injury with short term memory loss > and depression. She > has had a very thorough workup of her pain to date, > with no obvious > cause other than probable myofascial pain. I agreed > to see her and > prescribe darvocet, which I don't like much as a > pain medication,if she > would sign a medication contract which included > language about no > replacements if she loses medicine, dealing with the > pain medication on > visits only, and if she needed to contact me, on one > specific day of > the week only, and never after hours for the pain, > following through on > my recommendations, ... If she didn't abide by the > agreement then I > could dismiss her from the practice. She is also a > medicaid patient > and has been placed on a lockin program so that she > can only see one > doctor, go to one pharmacy, and one hospital. > She did pretty well for the first month,pain wise, > but hadn't followed > any other of my recommendations. Then she decided > to stop her > antidepressant and go without all medication, except > for her pain > medication for her chronic pain of course. I told > her that I would > agree to that as long as she tried something else, > such as yoga, Tai > Chi, or acupuncture. Which I have been talking > about since she first > started coming. She came into the office 2 days > later without an > appointment when I was out of the office, paged me > to talk with me, > told me that she thought her medication had been > stolen and the pain > was too much for her. I told her I would only talk > about it in the > office and she is coming in tomorrow, but it has > ruined the rest of the > day, as I just worrying about it. She still hadn't > tried anything else > that I have recommended to help decrease her > perception of pain. > So here she has violated several things on the > contract already, but > most likely because she is withdrawing from her > antidepressant which > she went off cold turkey on her own and recurrence > of the depression. > I agreed to see her tomorrow and I am torn about > whether to not give > her any more medication, to just go ahead and > dismiss her, or to > require that she restart her antidepressant, give > her enough medication > til her next refill next week. If I don't follow > through on the > contract, I am just a push over or am I being > sympathetic. , I > figure that one way or another, if she violates > anything further on the > contract after this visit that I will dismiss her. > I usually end up > being a pushover and I don't know if it is because I > don't want > confrontation or what. I hate spending all this > time worrying about > this. > > > Kathy Broman > Mason City, IA > kmlb2@... > > __________________________________________________ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 17, 2006 Report Share Posted March 17, 2006 Another thought on this situation - with her traumatic brain injury you describe she sounds somewhat cognitively impaired. Could someone argue that she can't understand the risks and benefits of opiate treatment and thus is not capable of signing a contract or consenting for treatment? What I'm getting at is that it is risky continuing to prescribe controlled substances to a non-compliant patient with impaired cognition. If there is some bad outcome (she overdoses, she injures someone in a car accident, she leaves kids in a hot car, etc.) you can be sure that some attorney somewhere will trace back blame to you, the intelligent prescribing physician, who should have known better than to prescribe mind-altering drugs to a poor, impaired individual who doesn't know as much about medicine as you do. I know I'm playing devil's advocate in this but I have seen people get burned trying to bend over backwards to help a patient like this - unfortunately, when the sh- hits the fan, people always look for the deep pocket to assign responsibility. I think you can give patients like this a choice - treat the pain with non-narcotic medications (antidepressants - both for depression and neuropathic pain, e.g. low-dose tricyclic, and anti-convulsants, NSAID's, etc.), or give her 30-day notice to find another provider. One analogy I use with patient is this: If I feel someone in the office has appendicitis, I know that the right treatment is further workup, CT, U/S, surgery, etc., I would not continue to give narcotics or analgesics indefinitely if the patient did not follow-through on work-up. I tell patients that pain is a complex condition that needs appropriate treatment (like your recommendations for Tai-Chi, yoga, etc.), not just refills on pain meds. I have found that this analogy helps with some patients. I want to emphasize that I do use long term narcotics successfully with many chronic pain patients - I am not completely against it - you just have to be comfortable with the relationship and ensure that a patient's function is improved with the opiate. Good Luck! Rancho Mirage, CA --- Kathy Broman wrote: > I have a question about how others handle difficult > patients and drug > seeking patients. I know that Pamela has commented > on this some. I > have a specific difficult patient in mind who is > coming in to see me > tomorrow. How hard nosed should I be, and when does > one go from > treating the individual and giving many second > chances, to being a push > over? What techniques do others use in similar > situations? I am not > sure if discussing particular patients is > appropriate for this forum > but this patient is representative of many other > similar patients with > similar problems. > This is a chronic pain patient who has been fired > from several other > clinics, due to not following through on drug > contracts, but also has > traumatic brain injury with short term memory loss > and depression. She > has had a very thorough workup of her pain to date, > with no obvious > cause other than probable myofascial pain. I agreed > to see her and > prescribe darvocet, which I don't like much as a > pain medication,if she > would sign a medication contract which included > language about no > replacements if she loses medicine, dealing with the > pain medication on > visits only, and if she needed to contact me, on one > specific day of > the week only, and never after hours for the pain, > following through on > my recommendations, ... If she didn't abide by the > agreement then I > could dismiss her from the practice. She is also a > medicaid patient > and has been placed on a lockin program so that she > can only see one > doctor, go to one pharmacy, and one hospital. > She did pretty well for the first month,pain wise, > but hadn't followed > any other of my recommendations. Then she decided > to stop her > antidepressant and go without all medication, except > for her pain > medication for her chronic pain of course. I told > her that I would > agree to that as long as she tried something else, > such as yoga, Tai > Chi, or acupuncture. Which I have been talking > about since she first > started coming. She came into the office 2 days > later without an > appointment when I was out of the office, paged me > to talk with me, > told me that she thought her medication had been > stolen and the pain > was too much for her. I told her I would only talk > about it in the > office and she is coming in tomorrow, but it has > ruined the rest of the > day, as I just worrying about it. She still hadn't > tried anything else > that I have recommended to help decrease her > perception of pain. > So here she has violated several things on the > contract already, but > most likely because she is withdrawing from her > antidepressant which > she went off cold turkey on her own and recurrence > of the depression. > I agreed to see her tomorrow and I am torn about > whether to not give > her any more medication, to just go ahead and > dismiss her, or to > require that she restart her antidepressant, give > her enough medication > til her next refill next week. If I don't follow > through on the > contract, I am just a push over or am I being > sympathetic. , I > figure that one way or another, if she violates > anything further on the > contract after this visit that I will dismiss her. > I usually end up > being a pushover and I don't know if it is because I > don't want > confrontation or what. I hate spending all this > time worrying about > this. > > > Kathy Broman > Mason City, IA > kmlb2@... > > __________________________________________________ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 18, 2006 Report Share Posted March 18, 2006 This is a disaster waiting to happen. Unfortunately, we can't save everyone. You need to dismiss her,PERIOD. She has broken your MUTUAL agreement. Working in New York City, I see more of my share of this type of behaviour. n Bobb-McKoy,MDKathy Broman wrote: I have a question about how others handle difficult patients and drug seeking patients. I know that Pamela has commented on this some. I have a specific difficult patient in mind who is coming in to see me tomorrow. How hard nosed should I be, and when does one go from treating the individual and giving many second chances, to being a push over? What techniques do others use in similar situations? I am not sure if discussing particular patients is appropriate for this forum but this patient is representative of many other similar patients with similar problems.This is a chronic pain patient who has been fired from several other clinics, due to not following through on drug contracts, but also has traumatic brain injury with short term memory loss and depression. She has had a very thorough workup of her pain to date, with no obvious cause other than probable myofascial pain. I agreed to see her and prescribe darvocet, which I don't like much as a pain medication,if she would sign a medication contract which included language about no replacements if she loses medicine, dealing with the pain medication on visits only, and if she needed to contact me, on one specific day of the week only, and never after hours for the pain, following through on my recommendations, ... If she didn't abide by the agreement then I could dismiss her from the practice. She is also a medicaid patient and has been placed on a lockin program so that she can only see one doctor, go to one pharmacy, and one hospital.She did pretty well for the first month,pain wise, but hadn't followed any other of my recommendations. Then she decided to stop her antidepressant and go without all medication, except for her pain medication for her chronic pain of course. I told her that I would agree to that as long as she tried something else, such as yoga, Tai Chi, or acupuncture. Which I have been talking about since she first started coming. She came into the office 2 days later without an appointment when I was out of the office, paged me to talk with me, told me that she thought her medication had been stolen and the pain was too much for her. I told her I would only talk about it in the office and she is coming in tomorrow, but it has ruined the rest of the day, as I just worrying about it. She still hadn't tried anything else that I have recommended to help decrease her perception of pain.So here she has violated several things on the contract already, but most likely because she is withdrawing from her antidepressant which she went off cold turkey on her own and recurrence of the depression. I agreed to see her tomorrow and I am torn about whether to not give her any more medication, to just go ahead and dismiss her, or to require that she restart her antidepressant, give her enough medication til her next refill next week. If I don't follow through on the contract, I am just a push over or am I being sympathetic. , I figure that one way or another, if she violates anything further on the contract after this visit that I will dismiss her. I usually end up being a pushover and I don't know if it is because I don't want confrontation or what. I hate spending all this time worrying about this. Kathy BromanMason City, IAkmlb2@...__________________________________________________ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 18, 2006 Report Share Posted March 18, 2006 Hi. Note how much time you have spent on this issue on one particular patient. You could have seen many more nice, not medicaid patients and not lose sleep over anyone of them. Might seem so calloused but word does get out on the streets and they will all come knocking on your door. Hardnosed, stubborn, calloused, call it what you want but narcotics and narcotics overdoses can come back and haunt you and there are a lot of legal counsel who would take a share of your goodheartedness and eat you alive. Just say no and they get the drift. Just make sure that you are closer to the door than the patient just in case they take it hard and might want to hurt you. That has happened before. This will upset you for now but you will be thankful. If they are new to your practice, mention " emergency prescription " on your script if you really really have to give it. Otherwise, dont ever put it on your DEA coz the feds will involve you too. At one time, I was the only physician that was receiving lock-in patients at my last employ. Medicaid referred people to me until i said no. So I guess make your own bed and make it nice and fluffy and serve those who you can help. grace > When a doctor is new in practice I think that they get an excess of > dug seekers. I made it a policy not to prescribe more than 10 days of > narcotics to anyone except my long time patients from my previous > practice and even then only to people who have a medical diagnosis > causing the pain. I have had numerous new patients come in for > narcotics for this or that and I kindly tell them that I never > prescribe narcotics and give them their co-pay back. I usually never > see them again. For my long time patient's who lose their > prescriptions I tell them sorry I can't refill their prescription > until the next one is due and ask them to be more careful in the > future. I take care of a lot of people with ADD. They really could be > losing their stimulant prescriptions due to their inattention but I > still don't refill their prescription early. Years ago when I wasn't > as careful I had a patient who got their prescription just a few days > early each month and sold the rest. I worked with someone whose 70 > year old grandmother was selling her narcotics to get a little extra > cash. > Larry Lindeman MD > > > > I have a question about how others handle difficult patients and drug > > seeking patients. I know that Pamela has commented on this some. I > > have a specific difficult patient in mind who is coming in to see me > > tomorrow. How hard nosed should I be, and when does one go from > > treating the individual and giving many second chances, to being a > > push > > over? What techniques do others use in similar situations? I am not > > sure if discussing particular patients is appropriate for this forum > > but this patient is representative of many other similar patients with > > similar problems. > > This is a chronic pain patient who has been fired from several other > > clinics, due to not following through on drug contracts, but also has > > traumatic brain injury with short term memory loss and depression. > > She > > has had a very thorough workup of her pain to date, with no obvious > > cause other than probable myofascial pain. I agreed to see her and > > prescribe darvocet, which I don't like much as a pain medication,if > > she > > would sign a medication contract which included language about no > > replacements if she loses medicine, dealing with the pain > > medication on > > visits only, and if she needed to contact me, on one specific day of > > the week only, and never after hours for the pain, following > > through on > > my recommendations, ... If she didn't abide by the agreement then I > > could dismiss her from the practice. She is also a medicaid patient > > and has been placed on a lockin program so that she can only see one > > doctor, go to one pharmacy, and one hospital. > > She did pretty well for the first month,pain wise, but hadn't followed > > any other of my recommendations. Then she decided to stop her > > antidepressant and go without all medication, except for her pain > > medication for her chronic pain of course. I told her that I would > > agree to that as long as she tried something else, such as yoga, Tai > > Chi, or acupuncture. Which I have been talking about since she first > > started coming. She came into the office 2 days later without an > > appointment when I was out of the office, paged me to talk with me, > > told me that she thought her medication had been stolen and the pain > > was too much for her. I told her I would only talk about it in the > > office and she is coming in tomorrow, but it has ruined the rest of > > the > > day, as I just worrying about it. She still hadn't tried anything > > else > > that I have recommended to help decrease her perception of pain. > > So here she has violated several things on the contract already, but > > most likely because she is withdrawing from her antidepressant which > > she went off cold turkey on her own and recurrence of the depression. > > I agreed to see her tomorrow and I am torn about whether to not give > > her any more medication, to just go ahead and dismiss her, or to > > require that she restart her antidepressant, give her enough > > medication > > til her next refill next week. If I don't follow through on the > > contract, I am just a push over or am I being sympathetic. , I > > figure that one way or another, if she violates anything further on > > the > > contract after this visit that I will dismiss her. I usually end up > > being a pushover and I don't know if it is because I don't want > > confrontation or what. I hate spending all this time worrying about > > this. > > > > > > Kathy Broman > > Mason City, IA > > kmlb2@... > > > > > > > > Quote Link to comment Share on other sites More sharing options...
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