Brief Answer:
Pain management clinic may help.

Detailed Answer:
After reading your concern I take it that you and your brother's biggest concern is about substance abuse? Are you also concerned about her living alone?

It is a hard situation when someone truly needs ongoing pain medications but may also be using more than is needed for control of their physical pain. But then the question is why are they using more? Sometimes people self medicate with narcotics to decrease depression or anxiety. And sometimes it is that people develop tolerance to the same amount of medication. Also, some narcotic forms are more likely to have abuse potential than others.

So I have a few suggestions:
1. A Pain Management clinic would be my first choice. I realize you may be restricted by Medicare but it might be covered given all of her pain causing pathologies. A pain management specialist can do a number of things:
- Provide pain management that is not predominantly narcotic based. They are experts in the choices and administration of meds for pain management.
- Provide any narcotic meds in forms that do not lead to an increased likelihood of abuse. For example shorter acting narcotics are more likely to lead to more substance abuse than narcotic skin patches, or "narcotic like" meds like Ultram.
- Hopefully address any underlying untreated depression.
- Develop a contract of pain management that she participates in so that she doesn't need to go to the hospital for Dilaudid.

2. A psychiatrist might be able to help with these things too, and might be covered by Medicare, and would help if there are any underlying mood disorders. They are not usually experts in pain management though.

3. Mental health practices such as mindfulness meditation can be helpful for decreasing pain and developing increased sense of control.

I hope these suggestions help. I'd suggest you look up the nearest pain management specialist or clinic and see if they accept Medicare, and if not, who they would suggest.

Please let me know if there is anything further I can clarify or information I can provide.

---

Brief Answer:
Start with Nursing Rehab Facility Social Worker.

Detailed Answer:
I am getting the picture a little better now.

If she is currently in a nursing rehab place, they likely have a social worker who comes in at least part time. Call the place and ask the social worker to call you back, and then express your concerns and your sister's history to him/her. They have considerable experience navigating such situations.

You can talk with your own doctor for ideas but he or she won't be able to help your sister unless your sister agrees to see him/her. Confidentiality laws. But since this is affecting you (losing sleep), it is reasonable to talk with your doctor for your own benefit. I doubt that he/she will tell you to stay out of it.

You can also ask your sister if she would mind either having you along when she next sees whoever is prescribing these meds for her (is it an orthopedic doctor?) and bring up the issue of concern about possible rx abuse (or maybe you can find a less negative word) and possibility of her going to a pain clinic. If she reports to her doctor that her pain is under control on the current regimen, you can supply the additional information that she goes into the hospital at times for Dilaudid. Sometimes ER reports go to the primary doc and not to a specialist such as him - so is it possible he is not aware of this?

Alternatively, if your sister would not be open to the above, you can call and talk with the prescribing physician and tell him/her what you and your brother are suspecting, and ask if it would be reasonable for her to go to a pain management clinic to decrease her use of opiates. While her doctor cannot talk with you about any details of your sister's case because of HIPAA laws, you on the other hand can fill him/her in on anything you want. The problem is if you feel this would damage your relationship with your sister.

The social worker can be an XXXXXXX for you and perhaps can approach your sister to discuss the issue,and perhaps encourage her to talk with her opiate- prescribing doctor about more all encompassing pain management via a referral to a pain clinic. Another piece that the (I am assuming the doctor is an)orthopedic doctor may not be taking into consideration is that in addition to the orthopedic pain, your sister has Felty's Syndrome, which is not something orthopedic surgeons manage. So her case is complicated by this. And for this reason, yes, you could encourage your sister to talk with her doctor that she may need more specialized pain management.

You can contact a Pain Management Clinic about Medicare and your sister's history, but they will not contact your sister themselves. However, if you are able (on your request) to talk with a nurse there on the phone and get information about what they provide, you can then present it to your sister as something positive that might make her better, and perhaps that would set the ball rolling.

It is good that you want to do what you can for your sister. But aside from researching what is available that might help her and perhaps trying to persuade her that these things will help her and should be pursued, that is pretty much all you can do. I hope this helps.

---

Brief Answer:
Your welcome, and I hope you are successful.

Detailed Answer:
One other thing: Xanax is strictly an anti anxiety medicine and is not used to treat depression.

And I hope you can find some peace of mind, too.

Best regards,
Bonnie Berger-Durnbaugh, MD

---