Pain pay sucks

[freddydpt]

When the patient talks about any pain not related to their joint of choice, they hear only the Charlie Brown teacher voice.

Exactly the reason why SDN needs a sound effect feature.

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[DOctorJay]

 

[Stim4me]

stay where you are, open up a solo practice, market/advertise heavy for 2 years, work hard, shake PCPs hands, have good patient outcomes, don't over medicate people, and then put your boss and corrupt CRNA out of business.... hard work pays off, even if the liberals think the term 'hard worker' is a derogatory phrase from the slavery days....

 

[Disciple]

All I ever get from ortho joint guys are med dumps. Botched knees started on percocet and dumped on me. Or 20 year olds with no pathology started on percocet and dumped on me. Ortho spine is a different story.

No direct experience working with or for ortho, but my experience is that they think pain = opioid management. When the patient talks about any pain not related to their joint of choice, they hear only the Charlie Brown teacher voice.

The spine surgeons send you patients for procedures, because you send them patients for lami/discectomy/fusion in return.

Assuming the joint guys aren't really aware of genicular nerve and hip RF, what kinds of patients would you expect them to send?

I would phrase my interactions with them as such:

"Hey Dr. so and so, I have a lot of patients to send for arthroscopy and hip/knee replacement, who have failed my injections and PT"

Surgeon: "Great, I would be happy to see them. Do you manage pain meds much?"

"Y'know, I used to, but I've gotten so busy doing injections that I do it very rarely nowadays. BTW, I've been doing this knee and hip RF procedure for failed arthroplasty patients. Results have been pretty impressive so far with no complications".

Of course, you'll have to do some marketing to the PCPs as well, so that you have good surgical candidates to refer to the joint/hand/sports surgeons.

 

[lobelsteve]

I have a local arthroscopist whose post op regimen for shoulders is this:
Percocet 10mg #50
Percocet 7.5mg #40
Percocet 5mg #40
Norco 7.5mg #40
Tramadol 50mg #40

I will be asking them out to dinner to discuss their surgeries (let them market to me), then I will try to gently offer advice regarding not giving 170 opiate pain pills then 40 Tramadol for an arthroscopic surgery.
I will wear a cheap outfit for when the wine gets thrown on me.

 

[BobBarker]

I don't know, Steve. I have seen very many painful shoulder scopes from my anesthesia days. That looks like he put some thought into it at least. I would want the percs myself if I had a shoulder scope. Knee scope? Nothing necessary really.

 

[ampaphb]

Bob: Percocet 10/325 is perfectly reasonable. A step down to one Norco dosage is also OK. However, that should be all that is required. 5 separate scripts? Significant overkill, unless the doc is concerned he needs 5 scripts to address his poor technique or underlying complications.

I don't practice orthopaedics. Orthopods should leave anything other than rudimentary pain management to those more expert in the field.

 

[Aether2000]

By the time the orthopedic surgeon has had the patient on opioids x 1 month, the damage is done and a percentage of these patients are now chemically dependent. The appropriate amount of narcotics would be on the order of 5 pills post op for arthroscopy and take ibuprofen/zipsor in lieu of creating addiction.

 

[BobBarker]

I guess my thought process is clouded from personal experience. I had a femur fracture when I was a teenager and I was in hindsight not prescribed strong enough medication.

 

[Aether2000]

A femur fracture has little to do with an arthroscopy. Femur fractures or any long bone fracture is accompanied by significant pain in most individuals, and I doubt anyone would fault either a surgeon or a patient for taking whatever was necessary to relieve the pain from the fracture and surgical repair. However the facts are compared to Europe, Americans take many times the amount of pain medication for post surgical pain and for a much longer period of time. Even when Europeans have opioids available for the treatment of postoperative pain, they use it much more sparingly than Americans, and tend to dispose of the majority of the opioid medications. Europeans are not lulled into believing opioids, even for acute short term use, are safe.

 

[Disciple]

Algos, you have to remember that we are more humane and just than the rest of the world.

No one in this country should have to be in pain.

 

[Stim4me]

Otho and spine folks dish out the opioids because they are fearful of being sued after equivocal surgeries( knee, shoulder, fusion)... Then they are told something else needs to be fixed, or they have "RSD" and it's out of their hands, off to pain management... We all know this game

 

[ampaphb]

Let's assume the 50 pills were written q4-6h. 10d supply of pills is a bit much, but not completely unreasonable.

 

[Aether2000]

In my opinion 50 tabs is an order of magnitude too large for post op arthroscopy pain. Consider the article http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1918645 that demonstrates the German MED post operative arthroscopic knee surgery is 13mg during the first 24 hours: equivalent to a little over one 10mg Norco. Our surgeons engage in gross overkill with opioids that ultimately creates the chronic pain issues of chemical dependency we all deal with.

 

[ampaphb]

As you point out, this is what was taken ON THE FIRST POST-OPERATIVE DAY. Not when the patients are active, undergoing PT, weight-bearing, attempting to regain ROM, etc. Makes no distinction between opioid naive and opioid tolerant populations.

Lovely study. Has absolutely no applicability to real world patients.

 

[Aether2000]

All our patients are weight bearing and active day one from arthroscopic surgery. And I would surmise most are opioid naive in this study because their surgeons and pcps are not so stupid as to load them up on opioids before surgery. This is exactly what should transpire in the us. Do you have a better study?

 

[ampaphb]

I see pain patients. Almost none are opioid naive. On the whole, they like to bitch and complain. The surgeons I work with do arthroscopy on an outpatient basis. If you think your folks are compliant with the home exercise program instructions they are given on post-op day one, you live in a different universe than the one my folks reside in.

I have started to see local surgeons infuse liposomal bupivicaine intraoperatively

 

[Aether2000]

Sounds like a technique with promise. My point is sugeons dont care if they are opioid naive or not...they have a standard excess prescribing formula for everyone and then give them more and more and more to shut them up rather than engage in a reasonable practice of medicine. Frequently the surgeons themselves create the fiasco by starting patients on 90 mg MED per day prior to surgery then cannot fathom why patients continue to need high doses after minor surgery. Germany and Holland do not have that problem.

 

[Papa Lou]

I guess my thought process is clouded from personal experience. I had a femur fracture when I was a teenager and I was in hindsight not prescribed strong enough medication.

not clouded. Realistic. I think giving someone a few percocets is inappropriate (in a way judgmental). 5 scripts is preposterous.

 

[Aether2000]

The appropriate way to manage opioids in acute pain is with small scripts. There is nothing judgmental in attempting to prevent chemical dependency, substance abuse, and very real long term use that occurs in 25% 2 years later. The problem is that surgeons are fundamentally lazy. When asked about why they write for so much opioid, their response (from several) was that they don't want the patient to run out on a weekend and bother them. That is why they were very upset when their favorite candy, hydrocodone, was moved to Schedule II- they actually had to physically write another script. Of course part of the problem is the expectation of high numbers of pills by patients after surgery.

 

[jsaul]

Otho and spine folks dish out the opioids because they are fearful of being sued after equivocal surgeries( knee, shoulder, fusion)... Then they are told something else needs to be fixed, or they have "RSD" and it's out of their hands, off to pain management... We all know this game

this is the exact truth... yes and after dishing it out freely for several months they then tell the patient "I cannot prescribe this anymore you must see pain management to continue the 6 percocets a day"

 

[yancantcook]

i find it really hard to be able to reduce the patient's opioid consumption after they have been on high dose opioids for a few weeks unfortunately. However, I think we can make a difference by using more non-opioids adjuncts and taper the patients off or tell the patient that we won't be able to continue this rx habit. usually, telling males that their testosterone will decrease significantly with prolonged opioid use may make them decrease the opioids

 

[ampaphb]

I have no problem. Steve taught me well. I'm the one with the pen. Stop trying to be liked, and just tell the patient what you are, and are not, willing to write.