effective strategies for pain pill seekers

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Hi , I am just finishing up a spine fellowship, what strategies do you employ with neck/back pain patients that effectively conveys that you are not part of a pill mill operation type physician, I know I will see a some number of neck/back patients who all they will want is there opioids and nothing else, basically I guess what I am asking is if in an interventional spine practice, is there an effective way to weed out pain pill seekers or is that just the nature of the beast,

in our fellowship, we very rarely prescribe opioids, but when out in the real world on my own, I think things might be different

Originally Posted by AndyDufrane

Hi , I am just finishing up a spine fellowship, what strategies do you employ with neck/back pain patients that effectively conveys that you are not part of a pill mill operation type physician, I know I will see a some number of neck/back patients who all they will want is there opioids and nothing else, basically I guess what I am asking is if in an interventional spine practice, is there an effective way to weed out pain pill seekers or is that just the nature of the beast,

in our fellowship, we very rarely prescribe opioids, but when out in the real world on my own, I think things might be different

are you looking to be a good doctor or have lots of patients?

If the former: Keep doing what you are in fellowship. Learn how to say no, and the word will spread and the drug seekers will not come to see you. It may take a while to build a practice.

If the latter: learn the mantra "no Rx unless we do an injection". I know MANY anesthesia pain docs who practice that way.

Simple answer - don't be a pill mill. If you prescribe them, they will come, and so will their siblings, aunts, uncles, friends, etc.

I let referring docs know I specialize in non-opioid-based pain. That doesn't mean I never prescribe them, just not very often. I turn down referrals for patients on big doses of opioids and for those I don't agree with them being on smaller doses, I don't prescribe, and document why.

For self-referred patients with chronic pain, they have to get me records to review. If they are on opioids, they are told they can see me, but I will not be preserbigin opioids for them. That keeps 95% of the pill-seekers away.

Also, even for referred patients, avoid Rxing opioids at the first visit, always do record reviews, check state databases and/or criminal databases, and do UDS.

As I tell docs in my lecture about opioids and chronic pain, if you don't prescribe opioids at the beginning of the pain syndrome, you won't be worrying about getting the patient off them later.

IME, 6 months on opioids = opioid patient for life.

Yep, and wasn't there a paper recently out of Denmark that showed that patients who took narcotics for chronic pain took 4 times longer to recover from their illness than patients who didn't.....Ahh, nope, here it is..

http://www.ncbi.nlm.nih.gov/pubmed/20842015

Had 4 times greater odds of recovery in the non-opioid group. I've been in Neurosurgery, Orthopedics, and EM...I'm moving into PM&R-Spine Practice. I'm not a big opioid prescriber, and I have a reputation among the patients who come to the ER with chronic pain.

I have no problem treating pain, and occasionally that requires opioids, but we have so many alternatives. I agree with the posters above about deciding which you want to be.

thanks everyone for the great input, greatly appreciated

Originally Posted by Thomas morgan

One of the greatest challenges in treating chronic pain is assessing for and monitoring potential

finish your sentence
potential ... what?

Someone else on here said in the past, which I think is a great and simple approach, that there are two hurdles to opioid tx:

1) right dx for opioids?
2) right pt for opioids?

Clear both those hurdles before rx'ing and everyone will be better off

Use the term "pain management" in your marketing, never "pain medicine", which you can then point to when patients demand drugs.

Send all your opioid takers to a known, liberal pill mill type of place, while you do the injections. Two guys I know who never prescribe anything more than Ultram do this. Though some would say this is no better than writing the heavy opioid scripts yourself.

Etc.

Originally Posted by Paddington

Use the term "pain management" in your marketing, never "pain medicine", which you can then point to when patients demand drugs.

Send all your opioid takers to a known, liberal pill mill type of place, while you do the injections. Two guys I know who never prescribe anything more than Ultram do this. Though some would say this is no better than writing the heavy opioid scripts yourself.

Etc.

you are responsible for your referrals. If you know that someone is incompetant, and send a patient there, you can be held responsible for generating that referral. NEVER send people to known "pill mills". Let them find them themselves (they will).

Originally Posted by Paddington

Use the term "pain management" in your marketing, never "pain medicine", which you can then point to when patients demand drugs.

Send all your opioid takers to a known, liberal pill mill type of place, while you do the injections. Two guys I know who never prescribe anything more than Ultram do this. Though some would say this is no better than writing the heavy opioid scripts yourself.

Etc.

I take a different approach. I simply tell them I do not agree with their use of opioids, and that I believe I have better ways of improving their lives. If they are not on huge doses of opioids, I will wean them off while we do other things, if they agree. If they do not agree, I tell them what I have to offer. Opioids are not what I offer.

I see pain management like a restaurant. You can go to a buffet and get as much as you want of anything you want for one price. That's a pill mill.

You can go to a chain restaurant where you have hundreds of choices, you are the customer, you decide what you want, but pay as you go. Food is ok, but hit or miss. That's primary care and others who take weekend courses to do pain.

Then there are the specialty restaurants. The chef only cooks a few things, but does them very well. The menu is one side of a piece of paper, not 12 pages. Choices are limited, but very few walk away unhappy. You can't order what's not on the menu.

I'm the last one.

Originally Posted by PMR 4 MSK

I take a different approach. I simply tell them I do not agree with their use of opioids, and that I believe I have better ways of improving their lives. If they are not on huge doses of opioids, I will wean them off while we do other things, if they agree. If they do not agree, I tell them what I have to offer. Opioids are not what I offer.

I see pain management like a restaurant. You can go to a buffet and get as much as you want of anything you want for one price. That's a pill mill.

You can go to a chain restaurant where you have hundreds of choices, you are the customer, you decide what you want, but pay as you go. Food is ok, but hit or miss. That's primary care and others who take weekend courses to do pain.

Then there are the specialty restaurants. The chef only cooks a few things, but does them very well. The menu is one side of a piece of paper, not 12 pages. Choices are limited, but very few walk away unhappy. You can't order what's not on the menu.

I'm the last one.

Very well said. Ultimately patients will realize that opioids are a means to an unfortunate end. It's hard to do but once you introduce new methods of therapy they realize opioids were causing more problems that they were solving. The difficult part is making them want to change when everyone wants an easy fix..hence fueling survival of pill mills. This is where being a physiatrist has it's advantages of more tools in the box leading to more satisfied customers who come back for a second helping of the good stuff ;-).

hello I was/am in similar situation... did a spine fellowship, not much opioid Rx experience, since had someone else in the dept. handling that...

I started reading "Responsible Opioid Prescribing" A Clinician's Guide, by Scott M Fishman, MD, concise and helpful, also cheap CME. The book is based on FSMB Model Policy (updated 2003) and APS-AAPM guidelines (2009)

You can order a copy online from the federation of state medical boards website FSMB.

those books are biased...

http://www.propublica.org/article/se...to-pain-groups

American Pain Foundation Shuts Down as Senators Launch Investigation
of Prescription Narcotics

As the U.S. Senate Finance Committee launched an investigation Tuesday
into makers of narcotic painkillers and groups that champion them, a
leading pain advocacy organization said it was dissolving "due to
irreparable economic circumstances."
The American Pain Foundation (Dr. Scott Fishman, chairman and
president of the American Pain Foundation until Jan 2012), which
described itself as the nation’s largest organization for pain
patients was the focus of a December investigation by ProPublica in
The Washington Post that detailed its close ties to drugmakers.
The group received 90 percent of its $5 million in funding in 2010
from the drug and medical-device industry, ProPublica found, and its
guides for patients, journalists and policymakers had played down the
risks associated with opioid painkillers while exaggerating the
benefits.
It is unclear whether the group's announcement Tuesday evening — that
it would "cease to exist, effective immediately" — was related to
letters sent earlier in the day from Sens. Max Baucus, D-Mont., the
finance panel chairman, and Charles Grassley, R-Iowa, to the
foundation, drug companies and others.
In the letters, the senators cited an "an epidemic of accidental
deaths and addiction resulting from the increased sale and use of
powerful narcotic painkillers," including popular brand names like
Oxycontin, Vicodin and Opana.


http://www.propublica.org/article/tw...-drug-industry

Two Leaders in Pain Treatment Have Long Ties to Drug Industry
Google Dr. Scott Fishman, chairman and president of the American Pain
Foundation, or Dr. Perry Fine, a prominent board member, and it's
quickly clear that their ties to the world of pain are legion.
In his initial JAMA disclosure, Fishman said he had written a book
about responsible opioid prescribing but received no royalties. In his
correction, he acknowledged receiving fees for teaching medical
education courses, some of which were funded by drug-company grants.

Over time, Fishman has had relationships with at least eight
companies, including OxyContin maker Purdue Pharma, for which he was a
consultant, paid speaker and recipient of research support. In an
email to ProPublica, Fishman said he had stopped taking money from
drug companies in recent years to avoid the perception of a conflict
of interest.

He does appear to maintain some ties. Last year, for example, he and
Fine appeared in videos on a website sponsored by drugmaker Cephalon
to educate patients about the safe use of prescription pain pills.
[Fishman's video was removed from the site after this story was
published.] Fishman's opioid book, written for the Federation of State
Medical Boards, was financed in large part by drug companies. The
federation would not provide specific dollar amounts.

Fishman, who is stepping down as chairman of the pain foundation this
month, said he often receives honoraria for teaching medical education
courses but doesn't discuss them with drug-company funders and
completely controls the content.

Fishman also said his position on opioids has evolved. He now believes
they are overused, often in cases in which the risks outweigh the
benefits. "Opioids represent only a small part of the spectrum on
options for mitigating pain, but they carry a disproportionate level
of risk," he wrote to ProPublica.