I'm back

Hello everyone. I've been away for awhile but I'm going to make an effort to do this again. Sorry to have let it go last year but some things got in the way.

The Florida Legislature is back in session and the NP controlled substance prescribing bill is once again languishing in first committee. The committee chairs in both the House and Senate refuse to allow it to be heard. If it isn't heard in committee it has no chance of going forward. If anyone has any pull with Senator Gaetz and will put in a good word for us it would be most appreciated.

I went to the AAHPM/HPNA Annual Conference in Boston and had a wonderful time. It was heavy on Pediatrics this year, which I am weak in, so I learned a great deal. I went to a particularly good lecture, Managing Neuropathic Pain in the Pediatric Patient, and some of it reinforced what I know and then some was new. I was reminded to try Ketamine for hyperalgesia, which I've never done. The next time I come across a case, I want to remember and see if I can get the MD I work with to help me with this. I've read of great results but it has to be done correctly. Conference is always stimulating and inspiring, and this was no different.

New this year was blogging for AAHPM, although it was disappointing to do a blog entry and have no comments. But it's great to have an organization so invested in being part of the technology of the 21st century.

I'm planning to submit a proposal for a presentation at next year's Conference. I'll be writing about it here in future entries. Here's hoping it gets accepted.

Prescriptive Authority Update

Once again, the State of Florida has ignored the facts and listened to the vested interests of the Florida Medical Society in denying Florida NPs the authorization to write prescriptions for scheduled drugs. In all fairness, I will say that many MDs spoke out on behalf of NPs, and the issue came much closer to reality than it ever has. Several MDs I've spoken with have been honest about the bottom line, that this is a turf issue, and that it's about power and money. I appreciate their honesty, but would like more that they would set aside their hubris and work for the real loser in this fight: the patient. From my viewpoint, this is about access to care, timely access, not just eventual access. They cloak their objections in talk of increased drug dependency rates, but in no state where NPs have this authority does this bear out.

However, Florida NPs are organized now as they have never been before. We have a plan for the summer while the legislature is out of session. We will bring this back next year, and the next, and the next, until the legislature finally does the right thing.

Why I Avoid Propoxyphene

Many clinicians use propoxyphene and its variants for pain control. I never do. In fact, the agency where I work has declared itself a "propoxyphene free zone". Independent studies have shown that it is no more effective than placebo at reducing pain. Any pain relief obtained is due to the acetaminaphen in the preparation and/or placebo effect. It is not on the WHO ladder for pain control. There are places in Europe where it is banned. The fact that propoxyphene is on the Beers list of drugs to avoid in the elderly is not entirely why I don't use it, because I do use drugs on that list for elders, but in small doses and while closely monitoring their effect. The primary reason is that it is so ineffective, especially for the kind of pain that most of my patients have, and there are so many other alternatives.

When I choose a pain medication, I want something that is not too strong, but not too weak. I usually give tramadol or hydrocodone, or morphine or oxycodone in small doses. I may even start with very low doses of methadone. It depends entirely on the clinical situation: reason for pain, level of pain, age of the patient, renal and liver function. These medications have a more predictable affect and can be adjusted easily one way or the other as needed. Oxycodone and morphine have long acting preparations, and methadone itself is long acting.

So I don't use this drug. It may have some use for acute musculoskeletal pain, in young people under 40. I'll be interested in your feedback.

I'm back

Sorry to have been away from this for a few weeks. Sometimes there is more to do than time to do it in. Between work and family obligations, I've had to take a breather. I hope to be back and posting more frequently.

Restraints

The use of restraints is an issue with large ethical as well as practical considerations. The Joint Commission has strict rules about their use, and in my facility we simply don't use them. The issues surrounding documentation don't exist for us, because we don't even own them. I suppose someone could make something out of rolled gauze, but they would be facing termination if they did.

So the question becomes, how do we control people who are out of control? First and foremost, we try to find the reason for the agitation. If this is a dementia patient, we try to meet their needs. If they need to walk, we find a staff member who can walk with them. If there is a toileting need, we help take care of that. We do use medications, from benzodiazepines to anti psychotics, which is a form of chemical restraint. We have also gone so far as to put the mattress on the floor to keep people from falling out of bed.

It's clear that tying people down makes the agitation worse, and is cruel and demeaning. Some may say that chemical restraint is just as bad, but I don't think so, because the person is still able to move about and interact. I try to give only as much as is needed for symptom control, not to render them completely helpless.

We're fortunate in my facility to have a staff/patient ratio of 3/8, and if the need arises for a 1/1 sitter that can be arranged. We are committed to never needing to restrain our patients, but to maintain their safety in other more creative ways. I'm interested in how others manage this problem.

Prescribing controlled drugs

One of the more frustrating aspects of working in Florida is that NPs are not allowed to prescribe any controlled drugs. Not just schedule II drugs, as in some states, but all scheduled drugs. The law not only confounds NPs in hospice and palliative care, but in nearly every other specialty. Psychiatric NPs can't independently prescribe Ritalin, and how often does one suppose there is the need? In my practice, I need to prescribe scheduled drugs every day. Because I work in an inpatient unit with a physician usually nearby, I can get things done fairly efficiently, but there isn't always a physician available.

So how do I manage? What I do, is write the orders, which means doing all the medical decision making, then the MD signs the order. All of the MDs I work with trust all of the NPs in our practice, and they may read the order but rarely question it. The extra step of getting the signature is time consuming and disruptive, and most importantly adds nothing to the process.

When I work on the home teams it's a different story. I carry a small laptop computer, and send the order by email to the team MD for signature. The MD may not be available at the time, or the technology may not be working so the email is slow to arrive. It can be hours by the time the patient finally gets the medication needed for symptom management.

For this reason, the NP groups in Florida have worked year in and year out to get legislation passed to reverse the law. The studies clearly show the safety of NPs prescribing scheduled drugs. The issue is about power and money. NPs in other kinds of practices have to have a "supervising" physician, who does nothing more than review charts on a monthly basis and is available to sign these kinds of prescriptions. The NPs have to pay the MD for this service, and in Florida many retired MDs use this to supplement their income. The Florida Medical Society supports many of the legislators, so it's difficult to get our bills through.

For me, the issue is really about access to care. While everyone is worried about power and money, people are not getting the care they need in a timely manner. To have to wait as much as 8 hours, as one patient I know did, for pain medication to finally be delivered, is criminal. If any one of these legislators had to wait like that, suffering pain and shortness of breath, there would no longer be an argument.

There seems to be more support in the Florida legislature this year. I'm hopeful. Stay tuned.

The psychiatric conundrum

This week I learned about Lithium toxicity. In the four years I've been practicing, it's just never come up, but I think that like Digoxin toxicity, I won't forget it. The hospice diagnosis was lymphoma, with a history of bipolar disease, treated at this point with Lithium. I've learned this week that Lithium is no longer considered the best drug therapy for this disorder, for exactly the reasons I found: levels are difficult to manage and even a bout of the flu affects concentrations.



I don't know what started the cascade, but somewhere in the past month the levels became toxic. Toxicity is exhibited by nausea, vomiting, and diarrhea, which lead to dehydration and increased concentration and further toxicity. If the person is unable to take the drug due to vomiting, there is self-weaning, but if they are not well educated about this, they will try to take the drug and keep it down. Double whammy. She was having myoclonus, fasciculations, and decreased level of consciousness.



By the time I discovered what was going on, she had not been able to take her medications for two days, so was self-weaning, but she was also having vomiting and diarrhea so her dehydration was counteracting that. I started an IV and got a blood level. The level was only 3 by this time, and people are only dialysed if over at least 4. And what was really going on was she was entering the dying process: remember the lymphoma diagnosis?



What this really underscores is the challenge of caring for terminally ill people with psychiatric illness. Psychiatry is not my forte, and I fumble whenever someone with a serious mental illness comes my way. I'm fortunate to have people to consult with, but it's hard to separate out some behaviors like anxiety and agitation at end of life. Which is the mental illness and which is end of life behavior? Are the hallucinations new or part of the schizophrenia? Does the patient understand their physical illness or does their mental illness prevent that?



So the next time I see a patient with nausea, vomiting, and diarrhea, and Lithium on the medication list, I'll stop the drug and get a level on the first day rather than the fourth. It may not change the ultimate outcome, but stopping the myoclonus and fasciculation would be worth it.