1/11. Chronic pain management: evaluating the use of opioids.A patient with chronic pain who is on multiple medications raises important questions for the case manager. Is the patient's underlying problem actually pain, or is it addiction? Has the patient been thoroughly evaluated? Does the patient have a coordinated management plan, or are several physicians independently writing prescriptions and recommending treatment? How can the case manager facilitate appropriate management?- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/11. Use of oral and implantable naltrexone in the management of the opioid impaired physician.Doctors are at an increased risk for prescription drug use, particularly opioids and benzodiazpines. This use can interfere with work function and has major potential negative implications for patient safety. Oral naltrexone, an opioid antagonist, has been used as part of a management strategy for opioid dependent physicians. While some patients stabilize on oral naltrexone, others relapse to opioid use. An alternative method of naltrexone maintenance involves the injection or surgical insertion of a sustained release preparation of naltrexone. This approach dramatically improves compliance, removing the onus from the previously opioid impaired physician to use daily oral naltrexone. This article describes the cases of four opioid-impaired doctors who received naltrexone (either oral or implant) as part of their management. The authors conclude that monitoring daily oral naltrexone use and detecting early opioid relapse is difficult, placing both the opioid impaired physician and their patients at risk. In contrast, by using implantable naltrexone, compliance is assured and opioid abstinence can virtually be guaranteed for five months. It is argued that naltrexone implants offer a level of protection not achieved with any previous treatment. It is recommended that management should involve early and close collaboration between the treating doctor and the Medical Board, with initial treatment, ongoing monitoring and follow-up being a Medical Board requirement for registration.- - - - - - - - - - ranking = 7keywords = physician (Clic here for more details about this article) |
3/11. Medico-legal rounds: medico-legal issues and alleged breaches of "standards of medical care" in opioid rotation to methadone: a case report.OBJECTIVES: The objectives of this medico-legal case report were the following: 1) To present an example of a medico-legal problem that developed as a result of a decision to rotate a chronic pain patient (CPP) to methadone in order to taper the CPP from oxycodone; 2) To present both the plaintiff's and defendant's expert witnesses' opinions as to if and where the care of that patient fell below the "standard of medical care;" and 3) Based on these opinions, to develop some recommendations on how, in the future, pain medicine physicians and other physicians should proceed, in order to avoid allegations of breach of "standards of care" when using methadone. methods: This is a case report of a CPP treated at a regional hospital pain clinic. methadone rotation was used in order to taper the CPP from oxycodone because of addictive disease. RESULTS: During the rotation process, the CPP expired. This had medico-legal consequences. Expert witnesses differed as to whether methadone caused the death. CONCLUSION: Pain physicians should proceed with caution in using methadone for opioid rotation.- - - - - - - - - - ranking = 3keywords = physician (Clic here for more details about this article) |
4/11. Abuse of prescription buprenorphine, regulatory controls and the role of the primary physician.INTRODUCTION: buprenorphine is an opioid partial agonist approved in several countries for the treatment of opioid dependence. It was approved in singapore in 2002 for this indication, and is more widely available in the primary care setting and can be prescribed by all licensed physicians who have undergone designated training. There is limited literature addressing the risk of its illicit abuse via intravenous self-administration. CLINICAL PICTURE: We report 2 such cases of the abuse of prescription buprenorphine in the psychiatric consultation-liaison service of a general teaching hospital, the treatment approaches and outcomes. CONCLUSION: We also briefly review the indications, uses and abuses of buprenorphine in singapore, and as reported in other countries, and the roles of primary care physicians, in order to stimulate greater awareness and understanding among specialists and general practitioners, who would encounter these patients in various settings.- - - - - - - - - - ranking = 6keywords = physician (Clic here for more details about this article) |
5/11. The identification and management of drug-seeking behavior in a medical center.We describe the development of a quality assurance program that monitors prescription medication misuse in a medical setting. The program focuses on patient activities that influence physician prescribing of abusable medications. Seven defining criteria have been developed to judge the presence of drug seeking by patients. When appropriate, a drug-seeking label is attached to the patient's chart and the hospital computer information system. The warning informs the physician and protects the patient from excessive medications.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
6/11. Unrecognized drug dependence and withdrawal in the elderly.The clinical diagnosis of drug abuse is frequently omitted from the differential diagnosis of transient fevers, arrhythmias and changes in mental status in the elderly despite the high risk of iatrogenic dependence in this age group. In pursuit of symptomatic relief from unrecognized depressions and from the chronic ailments of advancing age, the elderly receive many medications from numerous physicians. Therapeutic interventions are often duplicated or contradictory and result in the co-administration of tranquilizers, sedatives and analgesics. The result may be dependence which the patient and physician fail to recognize or to diagnose in the presence of withdrawal symptoms. In this report we present two such cases.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
7/11. Narcotic dependence in inflammatory bowel disease.Thirteen of 43 patients (30%) with inflammatory bowel disease referred for psychiatric consultation were found to be drug dependent, most commonly on oral narcotics. Drug dependence was more frequent in patients with Crohn's disease than ulcerative colitis and many had a borderline personality disorder. The study suggests that drug dependence is not recognized often enough in patients with inflammatory bowel disease and that patients with certain psychiatric disorders are at higher risk of developing it. Recognition of drug dependence is aided by interviewing family members. It is best prevented by seeking and treating the specific cause of pain and by having only one physician assigned to prescribe and manage narcotics.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/11. psychotherapy with the substance-dependent physician: pitfalls and strategies.psychotherapy with substance-dependent physicians presents special problems. Accurate assessment and effective response is rendered difficult due to underrepresentation or denial by the patient and countertransference impediments to recognition and limit setting by the therapist. Case examples illustrate problems, pitfalls, and therapeutic strategies.- - - - - - - - - - ranking = 5keywords = physician (Clic here for more details about this article) |
9/11. Treatment of iatrogenic drug dependence in the general hospital.Despite the vast literature on drug dependence, little has been written about patients who become addicted while taking medically prescribed drugs for organic pathology. Observations from a psychiatric consultation-liaison service reveal that these patients are frequently middle-aged with no history of drug abuse before the onset of a chronic medical condition. Associated with their medical condition is a dependence on narcotics and/or psychotropic medications for such complaints as pain, headache, insomnia, and anxiety. Thea addiction may persist for years without acknowledgement by a patient, doctor, or family, although there is usually a progressive constriction of social and occupational functioning. The primary physician is highly valued by the patient; this manifest appreciation trends to facilitate the primary physician's continued prescription of large doses of addicting drugs. Treatment involving detoxification typically goes through a series of stages, each of which has characteristic hazards and pitfalls that can lead to failure of treatment.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
10/11. Treatment of coexisting substance dependence and posttramatic stress disorder.This paper describes the treatment of a physician who developed posttraumatic stress disorder (PTSD) and a polysubstance use disorder after he was shot and held hostage by a patient. Inpatient treatment combined pharmacological and behavioral approaches, including systematic re-exposure via talking about the event in therapy groups. Standard methods for achieving and maintaining abstinence were used, such as asking for and accepting peer support and discussing painful feelings. Cognitive aspects of treatment included education about interactions between the two conditions. After 12 weeks the physician was free of symptoms and had minimal anxiety when exposed to salient cues of the traumatic event.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
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