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I presented a case to the UW Telemedicine Telepain yesterday. Wearing a dark navy silk suit, make up and my oxygen cannula.

The panel asked what my question was, since the patient is not on opioids. The vast majority of presented patients are on opioids.

There was another case first. A woman presenting about her husband, now dead of cancer. His cancer was fast moving. The oncologist said to get pain medicine from the primary care doctor and the primary care doctor said get it from the oncologist. Kaiser really sucked.

The pain medicine law in Washington State does not apply to oncology patients. Or end of life. You can dispense any amount of opioids. As needed.

However, it's not that simple. I have a patient who has a rare cancer who now has had it for a decade and seven recurrences. WHEN are we supposed to start giving the opioids? When they are diagnosed? No, because they might be cured or go into remission. Well, yes, if it's really painful. Well, careful now... And the panel said the WHO should be the oncologist. Well, that wouldn't work well for my patient because HELLO, for years you had to have a printed prescription wet signed and it could not be faxed. Ok, the rules changed during Covid-19 but most docs, including oncologists, require the patient to do a visit to refill the opioids. My patient lives two hours at a minimum from his oncologist. So I prescribed his opioids and kept track. He was fine, knew I was keeping an eye on him. I said this to the group. The panel avoided my eyes and didn't answer. Wusses.

Anyhow, the patient I presented has had four rounds of pneumonia and has not had a fever or white count with the last three and the question is partly diagnosis and partly now what? Has chronic fatigue and fibromyalgia, on oxygen and not recovering much, has a diagnosis of PANDAS from some psychiatrist who retired in 2013, the next one didn't agree....

Again, avoiding my eyes. The physiatrist (good decade older than me) says we have never (yet) found a cause for chronic fatigue or fibromyalgia. He recommended the usual graded exercise.

The dietician recommends supplements for mitochondrial support, the psychiatrist recommends duloxetine or one of those drugs, if PTSD is a factor then the anxiety response to SSRIs is not uncommon and tricyclics work better, start at a really low dose. Mirtazapine is a possibility or if sleep is an issue, prazosin could be tried. The new leader of Telepain reminds us about sleep and I mutter that the patient is scheduled for a sleep study, but that sleep improved with oxygen.

None of them said a word about PANDAS.

I did not really say much about psychiatric issues in the patient.

After all, we only had 15-20 minutes.

They are sending me consult recommendations in writing via email. I am sure the patient will very much appreciate this.

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