so what does pain medicine involve?

[anotherhopeful]

hi guys,

so i just met a resident whose husband is starting his pain medicine practice...and he's apparently doing procedures and booking ORs and procedure rooms to do stuff, which all sounds really really cool. i was just curious....what kinda procedures do pain medicine docs do and i'm guessing an anesthesiologist with a pain fellowship can do all this? and is it a lot more satisfying than taking care of chronic pain patients?

thanks!

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[g3pro]

Imagine a dark street corner in some inner-city of America. Imagine a man in a hooded sweatshirt sitting on a bench there, and in his pockets he has little baggies of "merchandise" to sell. People who want his "merchandise" know where to meet him, and they usually go there in the wee hours of the morning, typically around 2:00AM. That man is a drug dealer.

Now, change the setting to a clean, white-washed office, and a man sitting there in a long white coat at his desk. His customers, call them "patients", set up times to meet with him at certain points in the day, call them "appointments". They want to be "treated", which means giving them pieces of paper which can be taken to another location and exchanged for orange containers filled with "merchandise". That man is a pain fellowship trained anesthesiologist.

Basically, they're the same person. And they're both paid very well for their services.






At least that's what some zealots in the Federal government want you to think.

 

[aged]

A 2 day seminar by empire medical training for basic procedures and an additional day for advanced pain managment.
http://www.empiremedicaltraining.com/workshops.cfm

 

[amyl]

pain docs can do cool procedures like intrathecal pumps, electrical stim devices, epidurals for pain management, etc. there is also some medication managment... either its for you or not. either you like/don't mind the "pain" personality or you hate it. either you like the break from the OR to do some clinic or its torture. there is more to pain than cool procedures. there are several ways to pain, anesthesiology is not the only one, but still seems to be the best or at least easiest way to get into a top quality pain fellowship.

 

[polkadotcap]

I was surprised to learn that none of the anesthesiology-trained pain docs in my city do med management. They all say that they would be over-run with these types of cases if they did, so they are proceduralists only, and still enjoy a very busy and lucrative practice.....without the hassles of writing for narcotics on a monthly basis. Meds are prescribed by other types of pain docs- IM, psych, etc. They also have about an 8 month wait.

 

[Disciple]

It's not very realistic to do this anymore in most desirable/saturated locations.

Why?

Because the next proceduralist (who does the same stuff you do) will simply offer this service and let the PCPs/surgeons (especially PCPs) know about it.

There go your referrals.


If you take a close look at alot of high volume interventional pain clinics, you'll see that at many of them, once the patients stop getting meds from a particular physician, they stop going to that physician for injections.

 

[epidural man]

Imagine a dark street corner in some inner-city of America. Imagine a man in a hooded sweatshirt sitting on a bench there, and in his pockets he has little baggies of "merchandise" to sell. People who want his "merchandise" know where to meet him, and they usually go there in the wee hours of the morning, typically around 2:00AM. That man is a drug dealer.

Now, change the setting to a clean, white-washed office, and a man sitting there in a long white coat at his desk. His customers, call them "patients", set up times to meet with him at certain points in the day, call them "appointments". They want to be "treated", which means giving them pieces of paper which can be taken to another location and exchanged for orange containers filled with "merchandise". That man is a pain fellowship trained anesthesiologist.

Basically, they're the same person. And they're both paid very well for their services.






At least that's what some zealots in the Federal government want you to think.

Clever post......

In our pain clinic, we mostly have 70 year old ladies just wanting their back to stop hurting - not really looking for meds.

 

[urge]

hi guys,

so i just met a resident whose husband is starting his pain medicine practice...and he's apparently doing procedures and booking ORs and procedure rooms to do stuff, which all sounds really really cool. i was just curious....what kinda procedures do pain medicine docs do and i'm guessing an anesthesiologist with a pain fellowship can do all this? and is it a lot more satisfying than taking care of chronic pain patients?

thanks!

If you like that, why no be a surgeon? 90% of the pain guys I have met only cared about doing procedure$$$$. They didn't care for the patients. It's very sad.

 

[Noyac]

So what does pain medicine involve?


PAIN

 

[lobelsteve]

If you like that, why no be a surgeon? 90% of the pain guys I have met only cared about doing procedure$$$$. They didn't care for the patients. It's very sad.

I think it is more like 95-99%.

There are a bunch of mid-career pain guys that only do procedures, no medication management. We call them needle jockeys, needle monkeys, and feral injectionists.

Despite a lack of any evidence, every patient gets 3 epidurals (usally without fluoro). If no better they get MBB's and proceed to RF which doesn't work for most of their patients. If there is a whiff of radicular pain, the SCS is next. If there is PN of DM- they get an SCS to start.

The patients see us Pain Specialists (multidisciplinary folks) afterwards and are afraid of needles, nothing works, etc. We can fix some of them, and help out the rest.


As far as the hassles of opioids and seekers: I love it. Fact is opioids work well in the selected patient. My job is to select the right patient. I UDS every new patient and get targeted screens when I think I need to.
I had a guy falsify an MRI report to make his pain appear worse. I'm de-identifying it and posting it over on the Pain Forum. The guy was good, but not a doctor. Some non spine folks wouldn't know the difference.

 

[coprolalia]

I had a smoking, hypertensive 36-year-old obese lady who came in for a revision of her knee replacement following resection of a giant cell tumor of her lower femur. Here's what she was on (IIRC)...

-Methadone 10mg QD
-Oxycontin 80mg BID
-Actiq lollipops (usually 800mcg/day)
-Neurontin 800mg TID
-Nabumetone 2000mg QD
-Tylenol 1000mg Q6 PRN

She was still in intractable pain. She was so snowed in the pre-op area that I was worried about her ability to actually understand what was going on. Between drifting off to sleep, she mumbled about how much pain she was in. We blocked her leg in the holding area (lumbar plexus/sciatic).

Case went fine, dosed up the blocks with ropivicaine, and it took about four hours plus some cadaveric bone grafting. The whole time, I was running an infusion on the blocks and her hemodynamics were perfect. Dropped her Hb two points, but didn't have to transfuse her. Ran her at about half MAC just to keep her asleep. Used a tube because we thought it might have gone long and she also had GERD (but some attendings might have used an LMA still).

Anyway, woke her up, and she could not feel the extremity under maximal stimulation (i.e. a clamp applied to skin). She continued on and on about intractable pain and how much she hurt. The leg was completely blocked.

I have no explanation for this. Seriously thought in retrospect I should've used ketafol during the case instead of agent. I can't call this "phantom" pain, because the leg was still there. I surmised it was just opioid tolerance.

Now, I can't really understand why or how she'd gotten on this much narcotic, and I certainly couldn't understand the Actiq. She was a referral for surgery from an outside pain clinic/orthopedist who'd given up on her (basically). His note (outside bone doctor) even said "recommend amputation".

This case was a nightmare, and you occassionally get these kinds of patients in a pain practice. Long story short, this is why I could never do pain because this kind of patient would keep me up at night. And, life is just too short.

-copro

 

[epidural man]

I had a smoking, hypertensive 36-year-old obese lady who came in for a revision of her knee replacement following resection of a giant cell tumor of her lower femur. Here's what she was on (IIRC)...

-Methadone 10mg QD
-Oxycontin 80mg BID
-Actiq lollipops (usually 800mcg/day)
-Neurontin 800mg TID
-Nabumetone 2000mg QD
-Tylenol 1000mg Q6 PRN

She was still in intractable pain. She was so snowed in the pre-op area that I was worried about her ability to actually understand what was going on. Between drifting off to sleep, she mumbled about how much pain she was in. We blocked her leg in the holding area (lumbar plexus/sciatic).

Case went fine, dosed up the blocks with ropivicaine, and it took about four hours plus some cadaveric bone grafting. The whole time, I was running an infusion on the blocks and her hemodynamics were perfect. Dropped her Hb two points, but didn't have to transfuse her. Ran her at about half MAC just to keep her asleep. Used a tube because we thought it might have gone long and she also had GERD (but some attendings might have used an LMA still).

Anyway, woke her up, and she could not feel the extremity under maximal stimulation (i.e. a clamp applied to skin). She continued on and on about intractable pain and how much she hurt. The leg was completely blocked.

I have no explanation for this. Seriously thought in retrospect I should've used ketafol during the case instead of agent. I can't call this "phantom" pain, because the leg was still there. I surmised it was just opioid tolerance.

Now, I can't really understand why or how she'd gotten on this much narcotic, and I certainly couldn't understand the Actiq. She was a referral for surgery from an outside pain clinic/orthopedist who'd given up on her (basically). His note (outside bone doctor) even said "recommend amputation".

This case was a nightmare, and you occassionally get these kinds of patients in a pain practice. Long story short, this is why I could never do pain because this kind of patient would keep me up at night. And, life is just too short.

-copro

Sounds like a really tough patient. It is too bad someone not only wrote for those medicines but decided at some point to increase the dosing.

Lobelsteve says that it works sometimes (chronic opioid for non-malignant pain) but that isn't what the data shows. If a patient on workers comp gets opioids in the first week after getting "injured" on the job, that is an independent risk factor for not working in 1 year. Opioids for chronic pain suck (sorry lobelsteve). And so I don't mind when a "needle jockey" understands that no one on a morphine dose (or equivalent dose) of ~150 day is ever better with their meds. I don't think I have ever met a patient that was on that much morphine say, "I am so happy with my pain control." So when someone sees this and say's "well I don't know what will help you and I know that opioids are changing your physiology, your personality, and making you hurt more in the end, so maybe let's try a spinal chord stimulator." I just don't see anything wrong with that. This is exactly why the polyanalgesic pain something or other consensus panel just changed their first line treatment of intrathecal medicine to ziconitide cuz opioids just don't work. A SCS just might. That is why you trial them first.

Lobelsteve, I hope you do have great success with the patients and are able to get rid of all their opioids, or at least cut them down to a vicodan once or twice a week. I think it is great if you can do that. I also agree that we hear all the time from patients that they need to get 3 shots for it to work and we are constantly re-educating people that if the first one doesn't work, we won't repeat the second one (unless they really beg us too.) They get this idea from referring physicians by the way. And that's my other point. Most "needle jockies" get their patients from referrals for a procedure. I have never seen a commercial for a pain physician for self referrals, but I may be wrong. Most patients we see in our pain clinic are anxious to get a shot because PT, acupuncture, chiropractic care, pain soup meds, have not seemed to help.

I can also see why many pain physicians don't want to manage meds. Take copro's patient for example. This was completely inappropriate to have this patient on these meds. If a surgeon did a back surgery with hardware and it was all messed up, most neurosurgeons would send the patient BACK to the neurosurgeon to fix the problem and deal with their messup. It is the same thing. Most pain physicians would NEVER let the patient get that messed up, and that seems like what most med management is - that is - the FP has screwed up so bad, now they want you to fix it. That doesn't seem right.

 

[epidural man]

I think it is more like 95-99%.

(usally without fluoro).

I don't know of any board certified pain physicians (anesthesia pain boarded) that don't use fluoro. Plus, if they are all about money as you say, of course they are going to use fluoro.

 

[Disciple]

I can also see why many pain physicians don't want to manage meds. Take copro's patient for example. This was completely inappropriate to have this patient on these meds. If a surgeon did a back surgery with hardware and it was all messed up, most neurosurgeons would send the patient BACK to the neurosurgeon to fix the problem and deal with their messup. It is the same thing. Most pain physicians would NEVER let the patient get that messed up, and that seems like what most med management is - that is - the FP has screwed up so bad, now they want you to fix it. That doesn't seem right.

Well, like you said, most referrals come from PCPs or surgeons. What do you think is going to happen to your referrals if you don't take a few dumps here and there?

Most pain physicians don't like self-referrals, because that's a sure way to attract some of the hard-core drug addicts.


What can you do?


You can refuse alot of patients in academic practices. It doesn't fly in private practice, especially in areas where there's alot of competition.

 

[coprolalia]

Sounds like a really tough patient. It is too bad someone not only wrote for those medicines but decided at some point to increase the dosing.

Yeah, our pain clinic's "gestalt" is to try to get people off of opioids, not increase the dosing. But, this was a referral from an outside pain doc. And, I really don't understand the methadone+Actiq+oxycontin. That's a whopper-load of very potent narcotics. Usually, if we go down the methadone route, that's it. No other narcotics. Very dangerous to do otherwise. When I stuck the ETT in this patient, the initial ETCO2 was 55.

-copro

 

[Gator05]

"Despite a lack of any evidence, every patient gets 3 epidurals (usally without fluoro). If no better they get MBB's and proceed to RF which doesn't work for most of their patients. If there is a whiff of radicular pain, the SCS is next. If there is PN of DM- they get an SCS to start."

Sorry, despite a lack of any evidence is wrong.

http://www.guideline.gov/summary/su...r=005510&string=interventional+AND+techniques

Pain Physician 2007; 10:7-111.

The above is also not representative of the practice patterns I've seen.

 

[lobelsteve]

Sounds like a really tough patient. It is too bad someone not only wrote for those medicines but decided at some point to increase the dosing.

Lobelsteve says that it works sometimes (chronic opioid for non-malignant pain) but that isn't what the data shows. If a patient on workers comp gets opioids in the first week after getting "injured" on the job, that is an independent risk factor for not working in 1 year. Opioids for chronic pain suck (sorry lobelsteve). And so I don't mind when a "needle jockey" understands that no one on a morphine dose (or equivalent dose) of ~150 day is ever better with their meds. I don't think I have ever met a patient that was on that much morphine say, "I am so happy with my pain control." So when someone sees this and say's "well I don't know what will help you and I know that opioids are changing your physiology, your personality, and making you hurt more in the end, so maybe let's try a spinal chord stimulator." I just don't see anything wrong with that. This is exactly why the polyanalgesic pain something or other consensus panel just changed their first line treatment of intrathecal medicine to ziconitide cuz opioids just don't work. A SCS just might. That is why you trial them first.

Lobelsteve, I hope you do have great success with the patients and are able to get rid of all their opioids, or at least cut them down to a vicodan once or twice a week. I think it is great if you can do that. I also agree that we hear all the time from patients that they need to get 3 shots for it to work and we are constantly re-educating people that if the first one doesn't work, we won't repeat the second one (unless they really beg us too.) They get this idea from referring physicians by the way. And that's my other point. Most "needle jockies" get their patients from referrals for a procedure. I have never seen a commercial for a pain physician for self referrals, but I may be wrong. Most patients we see in our pain clinic are anxious to get a shot because PT, acupuncture, chiropractic care, pain soup meds, have not seemed to help.

I can also see why many pain physicians don't want to manage meds. Take copro's patient for example. This was completely inappropriate to have this patient on these meds. If a surgeon did a back surgery with hardware and it was all messed up, most neurosurgeons would send the patient BACK to the neurosurgeon to fix the problem and deal with their messup. It is the same thing. Most pain physicians would NEVER let the patient get that messed up, and that seems like what most med management is - that is - the FP has screwed up so bad, now they want you to fix it. That doesn't seem right.

The lady in the case presented needs a better doctor to fix her regimen or eliminate the opioids if they are not making her more functional. You took the liberty of taking my "opioids work for some people" and then painted a picture that opioids work for nobody. This is a ridiculous statement. The use of opioids is one tool we have as pain physicians to help our patients function better. It is the selection of the appropraite patient that is critical. You also favor SCS and Prialt as "first line treatments" . What if you were capitated? What if the reimbursement for SCS fell to that of an ESI? I think SCS should be done only after an IME by a BC Pain Physician because the docs doing a lot of these now are ruining the modality for the patients that will need them in the future. I've seen indications from FMS to made up CRPS (typically post-traumatic arthritis that gets relabelled to allow sympathetic blocks and SCS). The abuses in the field of pain medicine know no bounds. I think your training is brainwashing you to think like a needle monkey.

 

[lobelsteve]

"Despite a lack of any evidence, every patient gets 3 epidurals (usally without fluoro). If no better they get MBB's and proceed to RF which doesn't work for most of their patients. If there is a whiff of radicular pain, the SCS is next. If there is PN of DM- they get an SCS to start."

Sorry, despite a lack of any evidence is wrong.

http://www.guideline.gov/summary/su...r=005510&string=interventional+AND+techniques

Pain Physician 2007; 10:7-111.

The above is also not representative of the practice patterns I've seen.

This is not evidence, it is a summary statement from a political body. And they do not address the series of 3 that was recently refuted in Arch of PMR.

There does not appear to be any evidence to support the current common practice of a series of injections. Recommendations for further research are made, including a possible study design. Novak S, Nemeth WC. The basis for recommending repeating epidural steroid injections for radicular low back pain: a literature review. Volume 89, Issue 3, Pages 543-552 (March 2008)

 

[Idiopathic]

Theres certainly some quality literature on sensitization to pain as a result of long term opiate use, and this is often confused with tolerance. I usually consider this with patients like the one you described and use ketamine, regional, etc. Unfortunately, in my limited experience, this just sounds like a case of positive reinforcement gone awry. There almost has to be secondary gain involved.

 

[Gator05]

This is not evidence, it is a summary statement from a political body. And they do not address the series of 3 that was recently refuted in Arch of PMR.

There does not appear to be any evidence to support the current common practice of a series of injections. Recommendations for further research are made, including a possible study design. Novak S, Nemeth WC. The basis for recommending repeating epidural steroid injections for radicular low back pain: a literature review. Volume 89, Issue 3, Pages 543-552 (March 2008)

My issue wasn't against the series of three, it's the label of "lack of evidence" to each of the interventions you listed. And the link is a review of evidence, and a rather extensive review at that.

The PDF: http://www.asipp.org/documents/guidelines2007.pdf

 

[lobelsteve]

My issue wasn't against the series of three, it's the label of "lack of evidence" to each of the interventions you listed. And the link is a review of evidence, and a rather extensive review at that.

The PDF: http://www.asipp.org/documents/guidelines2007.pdf

Therein lies the confusion (mine). I agree the literature is highly supportive of MBB, RF, SIJ inj, SCS for CRPS and PLS. It is supportive for ESI for radicular but not axial pains, and against doing a series of 3. That is what I intended- that there is no evidence for doing a series of 3. I do the rest of that stuff daily. It's my job.

 

[GuP]

What are some of the bread and butter proceures of pain medicine?