Aiken SC doc for FBSS

[lobelsteve]

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Patient over 10 yrs. On 90meq and adjuncts. UDS/PDMP always appropriate. MRI 3/22 with no surgical pathology. Epidural fibrosis. Plan was SCS but moving to care for wife in Aiken. Will see back if care unacceptable. A chance to review my charts..... 😉

 

[paindoc007]

Dude, you the man. I’m all shy about asking what to do with my 4 patients on a whopping 40-60meq on this forum. And everyone gasps and can’t fathom I write doses soooo high. You boldly ask this here without apology. Love it.

 

[lobelsteve]

Dude, you the man. I’m all shy about asking what to do with my 4 patients on a whopping 40-60meq on this forum. And everyone gasps and can’t fathom I write doses soooo high. You boldly ask this here without apology. Love it.

I am a pain physician and was trained to be the guy who can write the medicines and keep control of the patients. If you stay within the guidelines and follow the rules and your patient has an excellent functional status with full-time gain from claimant, despite being 66 years old and able to retire, and I really don’t have any problem with what he is taking and I don’t have a problem prescribing it. Most of the guys saying they don’t write any medicines or they would never do this. Have a lot of skeletons in the closet. Also when anyone is anonymous and they say whatever they want they have less credibility. Here I am.

 

[Espn123]

I am a pain physician and was trained to be the guy who can write the medicines and keep control of the patients. If you stay within the guidelines and follow the rules and your patient has an excellent functional status with full-time gain from claimant, despite being 66 years old and able to retire, and I really don’t have any problem with what he is taking and I don’t have a problem prescribing it. Most of the guys saying they don’t write any medicines or they would never do this. Have a lot of skeletons in the closet. Also when anyone is anonymous and they say whatever they want they have less credibility. Here I am.

I respect that. But honestly in my fellowship I was NOT trained to manage meds like that. Too much to fit in to one year…

 

[Ducttape]

I respect that. But honestly in my fellowship I was NOT trained to manage meds like that. Too much to fit in to one year…

that is a poor reflection on your training program, unless you specifically trained at a "spine program".

i spend infinitely more time considering whether an opioid prescribing pattern for a patient is appropriate over what injection to do or how to do it.

 

[Agast]

Different training programs have different culture. Where I did residency was very anti-prescribing, in fellowship I learned a lot of med management. It’s a lot easier to say No to prescribing when it’s not part of your training…

 

[lobelsteve]

Different training programs have different culture. Where I did residency was very anti-prescribing, in fellowship I learned a lot of med management. It’s a lot easier to say No to prescribing when it’s not part of your training…

So no palliative care or cancer pain training? Weird the ACGME didn't shut the program down.

 

[MitchLevi]

Vast majority of ACGME pain fellowships will expose the trainee to a wide array of complicated opiate pts. Mine certainly did.

Fentanyl patches, OxyContin, Dilaudid, etc.

Meds I've never written for in PP.

I give oxy 5 or 10, Norco 5-10 and tramadol. I have a woman on MS ER for chemo neuropathy, but she's my only one on long acting opiates save one guy on Butrans.

Learning all of that opiate chaos in fellowship was critical to my development as a pain doctor, even though I don't take part in it.

 

[Agast]

So no palliative care or cancer pain training? Weird the ACGME didn't shut the program down.

I think there was zero palliative care, the cancer center managed their own pain patients. We had a lot of lectures on mindfulness and CBT as a substitute for narcotics. Norco was prescribed because it was still schedule III at that time, that probably changed later because no one got oxycodone.

 

[lobelsteve]

I think there was zero palliative care, the cancer center managed their own pain patients. We had a lot of lectures on mindfulness and CBT as a substitute for narcotics. Norco was prescribed because it was still schedule III at that time, that probably changed later because no one got oxycodone.

You got screwed. GOod to know what not to do and what you do not want to do, moreso than what you are asked to do.

 

[RM38]

We have an office near Columbia and get some patients from that area. It is probably a good 45-60 minute drive depending on where they live. Augusta University may have a clinic in Aiken as well. The one guy I know of that actually practices in Aiken I would not send to ever. I have seen a number of his patients and have been less than impressed to say the least.

 

[deleted875186]

Different training programs have different culture. Where I did residency was very anti-prescribing, in fellowship I learned a lot of med management. It’s a lot easier to say No to prescribing when it’s not part of your training…

Agreed, I think everyone agrees opioid prescribing is the worst and most challenging part of the job. It’s easier to just not do it if you have the setup.

 

[Espn123]

that is a poor reflection on your training program, unless you specifically trained at a "spine program".

i spend infinitely more time considering whether an opioid prescribing pattern for a patient is appropriate over what injection to do or how to do it.

Did your fellowship lack strength in one aspect of pain in return for more exposure to another? Hopefully it was perfect

 

[GoBeers]

if a pain physician doesn't want to prescribe opioids then so what?
similarly if a fellowship doesn't involve opioids then so what?
you don't need a fellowship to figure out what's right or wrong with opioids

what opinions do you have regarding your ortho colleagues who don't treat knee arthritis pain because "they're too young or not a candidate for knee replacement?
what opinions do you have regarding your rheumatology colleagues who don't treat pain related to clear cut rheumatoid arthritis if they fail tramadol?
what opinions do you have regarding gastroenterology "specialists" if they refer patients to you to manage functional abdominal pain?

 

[lobelsteve]

if a pain physician doesn't want to prescribe opioids then so what?
similarly if a fellowship doesn't involve opioids then so what?
you don't need a fellowship to figure out what's right or wrong with opioids

what opinions do you have regarding your ortho colleagues who don't treat knee arthritis pain because "they're too young or not a candidate for knee replacement?
what opinions do you have regarding your rheumatology colleagues who don't treat pain related to clear cut rheumatoid arthritis if they fail tramadol?
what opinions do you have regarding gastroenterology "specialists" if they refer patients to you to manage functional abdominal pain?

Experience. Education. Training. Fellowship must teach you these things. What you do in practice is up to you. Go look up the PIF for ACGME fellowship programs.

 

[deleted875186]

Experience. Education. Training. Fellowship must teach you these things. What you do in practice is up to you. Go look up the PIF for ACGME fellowship programs.

I don’t think opioids need to be prescribed in fellowship. If Yoj want to make it a part of practice that can be done without doing a year of prescribing opioids to people, so long as farmikiar with urine monitoring, risk stratification, etc.

 

[Ducttape]

i respectfully disagree. there are skills that are easy to pick up.

the skills of being able to cogently discuss appropriate opioid use, when one side is so heavily biased for its use, is something that requires much greater skill than any injection.

i mean, if you want to say to everyone "i dont prescribe at all, i only do shots, get out", fine. you dont need fellowship training. but to do opioid prescribing in the safest manner is in my opinion not something one can just pick up - otherwise all of those PCPs out there would never get to these astronomical and inappropriate doses.