I am a primary care NP, working with 2 MDs and 2 other NPs. Recently, I had a 90 years old patient, who has post herpetic neuralgia, had shingles 2 years ago. She has h/o diabetes, dementia, sciatica and hypothyroidism. Pt had a fall a year ago, broke her left hip, hemiarthroplasty done. This patient was on oxycodone 5 mg tid prior to the fall for her sciatica, which was tapered off recently in September. After her shingles, she was started on gabapentin 300 mg hs. Patient came this time to the office with her aide, who is with her for 10 years, complaining of neuralgic pain on the left side of her body, more in lt mid back. Aide insisted that gabapentin is not working, patient needs oxycodone back and the patient's daughter is also insisting for oxycodone. I tried to explain the risks, aide would not listen to me. She threw a storm at me. Patient is demented, has no say. I increased the gabapentin to 300mg bid, lidoderm patch for the left mid back and asked her to follow up in a month to see the change. I called the patient's daughter and explained, which she understood. Later, the office manager told me that this aide was collecting patient's medications from the pharmacy, (reported by the pharmacist), who knows whether the patient was getting oxycodone in the past or the aide was using/abusing it? What would you do here?
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We urine test everyone even the very elderly for just this reason. You know what the national average is for non-consistent urine screens in primary practice? Almost 70%. 6-7 out of 10 patients either have meds they weren't prescribed present and/or meds that are prescribed absent.
I just re-read the OP and see no mention of having done an actual pain assessment of the patient. Nor does it mention what clues are used by the caregiver that the patient is in pain as opposed to hungry, constipated or needing to pee ... all frequent causes of agitation in demented patients.
The automatic assumptions expressed in this thread are a large part of why many people don't even bother with medical practitioners unless/until it's unavoidable.
I just re-read the OP and see no mention of having done an actual pain assessment of the patient. Nor does it mention what clues are used by the caregiver that the patient is in pain as opposed to hungry, constipated or needing to pee ... all frequent causes of agitation in demented patients.
The automatic assumptions expressed in this thread are a large part of why many people don't even bother with medical practitioners unless/until it's unavoidable.
I thought it went without saying the patient had been assessed for pain considering that was a caregiver complaint.
I thought it went without saying the patient had been assessed for pain considering that was a caregiver complaint.
Not necessarily - it certainly wasn't evident from the OP. If you're correct, then the OP seems to have been edited to encourage the care-giver-is-a-junkie scenario. I agree that it's certainly possible by it's not the only possibility. (BTW, was high-dose topical capsaicin considered for the post-hermetic neuralgia?)
I just re-read the OP and see no mention of having done an actual pain assessment of the patient. Nor does it mention what clues are used by the caregiver that the patient is in pain as opposed to hungry, constipated or needing to pee ... all frequent causes of agitation in demented patients.
The automatic assumptions expressed in this thread are a large part of why many people don't even bother with medical practitioners unless/until it's unavoidable.
Most assumptions were related to as you pointed out the limited information provided. But most of its see these issues so regularly, it's easy to validate the OP concerns and thoughts about what is going on here. I've discharged two patients this week alone from our practice for a combination of prescribed medications not showing up on uds with a mix of other controlled substances showing up that weren't prescribed. What you describe as unwarranted presumptions are likely based in reality.
Most assumptions were related to as you pointed out the limited information provided. But most of its see these issues so regularly, it's easy to validate the OP concerns and thoughts about what is going on here. I've discharged two patients this week alone from our practice for a combination of prescribed medications not showing up on uds with a mix of other controlled substances showing up that weren't prescribed. What you describe as unwarranted presumptions are likely based in reality.
Having practiced at the bedside for 40+ years, I'd be an idiot to claim that diversion, drug-seeking and scamming the system to support a habit don't exist. I'd be worse than an idiot to assert that practitioners shouldn't keep a weather eye out for such scams.
On the other hand, getting distracted by preconceptions and unconscious "hierarchies of pain" (IOW, some patients are innocent victims while others did it to themselves or aren't in "real" pain) can blind us to what's really going on with this confused elderly lady. It would be a shame for her to die in unnecessary pain because her caregiver's report was dismissed as drug-seeking.
I do not get this philosophy of being very elderly is pushing it on narcotic pain relief. Yes, I understand where concerns come in as in it could mask some dementia s/s, increase fall risk etc...but if someone is going to be in pain for the rest of their lives they should not have to spend whatever time they have left in constant pain which they likely will more due to the 'War on drugs' part two rather than side effects. Heck, lets talk about the side effects of everything else. Warfarin, the active ingredient in rat poison comes to mind as do anti-hypertensives but when it comes to narcotic pain meds or benzodiazepines doctors begin not treating conditions which will not improve.
As to posters who mentioned the elderly woman's' aide being overly interested in Rx the 90 year-old would have to pee in a cup and have that UA be + for what she is prescribed. While I despise the government intrusion inserting itself into Dr: Pt relationships I think it is a good idea to obtain a urine sample from those who cannot verbalize not receiving their pain medication.
We have gone off the deep end in nit treating pain. My mom had advanced dementia and I respected her wishes in no tube feeds etc...I did ask doc to keep fentanyl patch on in event she had pain she could not verbalize but this was @ 12 years ago, well before the pendulum swung toward not treating anyone.
Urine test everyone involved (weekly, if you feel the need), then think about quality of life for this little lady who most likely doesn't have a lot of years left.
Death from respiratory depression from oxycodone TID? Not likely unless she already has one foot in the grave and the other on a banana peel in which case she should be under hospice care. And 'high' on PO meds? Have not seen any patient get high on POs and you show your hand with that comment. I don't use anything more mood altering than coffee, I also do not take inventory of others. If said 90 year-old were looking for a buzz I'd think she'd have a bit of a history with ETOH; you know, that widely accepted drug which only purpose is to alter ones' mood and which many of the more self-righteous imbibe in freely. I pray I do not live to be 90 with providers basing most of their decisions on fear of the DEA rather than fear of the patient functioning.
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We urine test everyone even the very elderly for just this reason. You know what the national average is for non-consistent urine screens in primary practice? Almost 70%. 6-7 out of 10 patients either have meds they weren't prescribed present and/or meds that are prescribed absent.