Physical Medicine and Rehabilitation - Case Seven
Ms. Fennel is 50 years old and has had back pain since her early 20s. She was hospitalized in the mid-1980s for a herniated disk and subsequently had back surgery. She says the surgery helped, but "only until I sat up." She admits that about ten years ago she started using alcohol to manage her pain, but has since stopped drinking. She is taking what you consider a significant dose of opioids prescribed by her previous physician. You have her sign a pain contract in which she agrees to only obtain prescriptions from you. You have prescribed Methadone and Zanaflex. Within a month you discover that she is obtaining Percocet and Soma from other doctors.
- A. How would you approach the patient (either cooperative or resistant)?
- B. What data do you need to collect or what initial screening should be done?
- C. What other medications/drugs is the patient using?
- D. What is the pattern of patient's medication/drug use?
- E. What internal/external obstacles and biases might the patient face?
- F. What internal/external obstacles and biases might the physician face?
- G. What do you do now?
- H. How does the physician make a referral?
- I. When and how should the physician follow up with the patient?
A. How would you approach the patient (either cooperative or resistant)?
(The goal is to develop a positive, non-judgmental rapport with the patient.)
- Use your rapport. Affirm the patient for being honest.
- Don't be afraid to explore the issue.
- Display compassion and concern.
- Ensure confidentiality
- Use a neutral, matter of fact, tone of voice
- Acknowledge it may be difficult for the patient to share this information.
- Be nonjudgmental. Remember this is a disease. The more nonjudgmental you are the more likely the patient is to reveal information.
- Allow any resistance, pre-contemplation, and minimization to be okay. Remember to be nonjudgmental and avoid any power struggles. At this time it is unnecessary for the patient to admit that he has a problem.
- If patient is resistant, acknowledge that it is difficult and uncomfortable and explain that you believe this is a health issue and is part of your over all approach to patients. Continue to gently ask questions.
- Be redundant. If your questions are not being completely answered ask again.
- Phrase the question appropriately. For example, ask, "Tell me why you think you need more Percocet?"
(The goal is to gather relevant history and barrier information.)
- The potential overuse of Percocet in this patient should raise concern of liver toxicity and drug tolerance.
- The motivation for use will help you determine if there is an addiction or whether the pain is being under managed.
- An addiction (according to the Diagnostic and Statistical Manual of Mental Disorders DSM-IV)is defined by the biopsychosocial consequences of use, not just frequency and amount. Ask the following questions:
- a. Why are you getting prescriptions from other physicians?
- b. Tell me how you are taking the medications?
- c. Have you been prescribed pain medication in the past? (Get history of pain medication use, for what purpose, for how long it was used.)
- d. Have you ever lost prescriptions in the past or run out of your refills early?
- e. What types of symptoms do you experience when you go without the medications?
- f. What kind of pain are you still experiencing?
- g. How do you feel after you've taken the medications?
- h. Has anybody expressed concern regarding your medication use?
- i. Have you ever been in treatment for alcohol or drug abuse?
- j. Have you ever had any alcohol or drug-related arrests?
- k. Have you been missing work, school, or family responsibilities?
- l. Do you typically drive after taking medication?
- m. Do you have arguments with people in your life regarding your behavior when you are taking medication?
- n. Would you consider taking another medication to manage your pain?
- o. Would you consider approaches other than medication for managing your pain?
If the person becomes resistant or uncooperative try to reassure the patient that you are gathering this information to provide the best care for her health. If the patient remains resistant then ask her what she would like to do and consider whether it is an appropriate request.
- Review the patient's medication use to look for interactions or contraindications in a patient who is using Percocet.
- Review medications from any other prescriber. If you suspect the patient is minimizing or omitting other sources of medication, do a search on the Utah State Controlled Substance Database (csdb.utah.gov).
- Ask specifically about "pills." Such as "Do you ever take any other kind of pills?" and "Do you ever take anyone else's pills?" Find out whether the patient is taking antianxiety medication, e.g., Xanax, Valium, or Klonopin. (Note: It is important to ask specifically about pills, as many people do not consider pills to be drugs of abuse.)
- Review history of alcohol and illegal drug use. If currently using alcohol or illegal drugs, ask questions as noted in section B. (Reminder: Do not use the term "illegal drug". Instead ask "tell me about your drug use." Or ask specifically about certain drugs such as "tell me about your marijuana use.")
(The goal is to determine when, how often, and under what kind of stress/pain conditions is the patient using/abusing the prescribed medications or other drugs.)
(The goal is to determine how receptive/resistant the client will be to a discussion regarding his/her drug use. The physician needs to be aware of the internal/external stigma and biases that the patient faces. The physician will need this information to determine how best to approach the patient.)
Fear that her pain won't be treated. (Keep in mind that individuals with addictions may still have real pain that needs to be treated.)
Fear of change, facing the knowledge that they have a serious problem, reprisals, treatment, being branded as an addict.
Embarrassment and shame.
Fear of rejection by friends or culture.
The patient's belief that her prescription drug use is not problematic.
Lack of insurance for treatment.
Residing with somebody who has an addiction.
Being a primary care-taker of children (Childcare may be needed while patient is participating in treatment.)
Fear of loss of employment.
Fear of legal ramifications if they feel they are divulging sensitive information.
Society's stigma and blame.
Belief that addiction is a moral issue and not a medical issue.
Belief that he couldn't possibly be in this much pain.
Belief that people with addictions don't deserve to be treated for their pain.
Belief that treating pain among people with addictions will exacerbate their addiction.
Belief that treating pain with opioids will cause an addiction.
It is easier and quicker to just fill the prescription rather than assess for pain and addiction.
Lack of treatment availability (affordability, waiting-lists, services not available in community)
Physician's discomfort with addressing substance abuse issues
Physician's family history causes countertransference (misperceptions based on personal experiences).
(This provides the physician with the information he/she needs to provide appropriate referral/treatment services.)
- Discuss evidence for concern (possible elevated LFTs due to excessive use of Percocet, running out of prescription early, possible results of Utah State Controlled Substance Database, any biopsychosocial concerns identified in part B)
- Display compassion (Remember that addiction is a life threatening disease thus show the same sensitivity as you would for identifying any other life-threatening illness, such as cancer.)
Provide reassurance that it is treatable.
Ask the patient how she feels about your concerns.
Address the stigma associated with having an addiction by reassuring the patient that this is a medical illness and not a question of moral character.
The physician can discuss other approaches to managing pain, including hot/cold packs, exercise, physical therapy, relaxation, and Lidoderm patches.
If it is determined that the patient is not experiencing pain but does have an opioid addiction, consider prescribing Suboxone for detoxification or maintenance treatment and coordinate with a substance abuse treatment provider.
If it is clear that there is significant clinical impairment in the patient's biopsychosocial functioning as a result of her Oxycontin use, the patient should be referred to a substance abuse treatment provider for further evaluation and treatment.
If the patient is receptive:
If the patient does not have insurance that covers substance abuse treatment, or does not have the ability to pay for treatment, or if the physician has no knowledge of substance abuse treatment agencies, refer to SL County Division of Substance Abuse at 468-2009 or refer directly to Interim Group Services.
If the patient is a veteran, eligible for VA services (this typically means having been honorably discharged) refer to VA Salt Lake City Health Care System at 582-1565.
Ideally physicians should begin to develop relationships with substance abuse treating agencies and can refer to a specific agency for treatment. However, the physician should encourage the patient to call his insurance company to determine what services are covered.
Regardless of the specific referral, the physician should list the name of the agency and the phone number on a prescription blank and give to the patient. If there is sufficient time, it would be helpful for the patient to make the phone call in the physician's office; this demonstrates concern and active interest on the part of the physician.
If the patient is not receptive:
If the patient remains resistant then consider restricting her to weekly prescriptions that she must pick up at the office and request Utah State Controlled Substance Database checks regularly. Some physicians have patients sign a pain management contract.
The physician should write down the name of the agency and the phone number and encourage her to follow through with the referral.
(This provides the physician with the opportunity to coordinate with other agencies/providers in order to deliver comprehensive services for the patient. It also provides the physician the opportunity to take an active role in the patient's substance abuse problems. The physician can treat/oversee the substance abuse problem as any other medical condition that can have a positive outcome.)
If there was a referral:
Physician should obtain a release of information from the patient and provide referral information to the treating agency regarding concerns. Respond to any requests for information from the treating agency.
Physician should ask the patient if they followed up with their referral and discuss resulting actions. Reinforce and encourage continued participation in treatment.
In case of severe addiction, physician should coordinate directly with treating agency.
If there was no referral:
- Discuss patient's progress toward reducing or eliminating alcohol use. Ask specifically about activities or strategies that the patient used to accomplish that goal. Congratulate successes.