for pain pills pushers

[2win]

When it is the time to recognize that pain medicine is a total failure? What is the contribution of the pain management field in the opioid epidemic? Just have the balls to recognize that is useless . You want facts? What's the percentage of patient post interventional procedures without opioids and productive? Just spit it on "pain doctors"!

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[yellowdonkey]

When it is the time to recognize that pain medicine is a total failure? What is the contribution of the pain management field in the opioid epidemic? Just have the balls to recognize that is useless . You want facts? What's the percentage of patient post interventional procedures without opioids and productive? Just spit it on "pain doctors"!

What is this about? Lol. Do you have personal experience getting care from pain docs? Of course nothing is perfect in the field of medicine, but I know theres plenty of patients in pain with improved quality of life due to pain docs who manage them with excellent care

Sent from my SM-N900V using SDN mobile

 

[yellowdonkey]

I dont think you can directly associate the opioid epidemic hand in hand with pain medicine. Pain docs arent the only ones giving opioids. Theres your street dealers, family docs, ER, psychiatrists, neurologists, on and on

Sent from my SM-N900V using SDN mobile

 

[Prometheus123]

Maybe look in the literature for novel analgesics and find a PI who will let you do a small clinical trial of the most promising one if there's enough evidence for safety in humans? These look interesting:

Opening paths to novel analgesics: the role of potassium channels in chronic pain
Drug Repurposing for the Development of Novel Analgesics
The search for novel analgesics: targets and mechanisms

I'd also look into phosphodiesterase 4B and 5 inhibitors. PDE 4B inhibitors are potent anti-inflammatories via TNF-alpha inhibition, they've been shown to decrease alcohol dependency in rats (they may help with opioid dependency in humans too), and I found a couple studies showing they can have a chronic analgesic effect. PDE 5 inhibitors have also been shown to have an analgesic effect.

Be a hero and solve the problem. We'll all thank you for it.

P.S. To save time, you can get an app called VoiceDream for your phone that will read PDFs (including papers like this) to you while you commute.

 

[Hoya11]

When it is the time to recognize that pain medicine is a total failure? What is the contribution of the pain management field in the opioid epidemic? Just have the balls to recognize that is useless . You want facts? What's the percentage of patient post interventional procedures without opioids and productive? Just spit it on "pain doctors"!

Yay! I hope this is a serious post because I agree 100%!

 

[Hoya11]

What is this about? Lol. Do you have personal experience getting care from pain docs? Of course nothing is perfect in the field of medicine, but I know theres plenty of patients in pain with improved quality of life due to pain docs who manage them with excellent care

Sent from my SM-N900V using SDN mobile

Maybe its because were all fed up catering to this pathetic, wasteful, selfish, draining, wimpy population for the right to bill them for sedation. Oh you need propofol do you? You dont want to feel anything huh? Get out of my center and stop wasting everyones time with your multitude of BS

Different from those other fields, pain would be completely gone without opiates.

Now cue the SDN minions who all have purely interventional practices where everyone is doing great and hardly anyone gets opiates.. sure...

 

[Orin]

Just have the balls to recognize that is useless . You want facts? What's the percentage of patient post interventional procedures without opioids and productive?

Remind me of the utility of most of the surgeries we provide anesthesia for?

 

[Prometheus123]

Do you guys have a sense of what most often caused the pain they originally got the opiates for? Is it usually for post op pain?

 

[Lecithin5]

While there are some pain docs that are part of the problem, many try to be part of the solution. Remember, PCPs are the main fuel behind the opioid epidemic. Pain docs are getting referrals from these pcps who have inappropriately been prescribing opioids and/or benzos, and having to rectify the mess.

 

[2win]

What is this about? Lol. Do you have personal experience getting care from pain docs? Of course nothing is perfect in the field of medicine, but I know theres plenty of patients in pain with improved quality of life due to pain docs who manage them with excellent care

Sent from my SM-N900V using SDN mobile

Fortunately I don't have the experience of being a patient in a pain clinic. But maybe compared with you I had a pain clinic. And please show me the data - maybe you remember EBM regarding the benefits of pain medicine . Nobody cares about your personal opinion you can post it on facebook - if you are a scientist is all about data. If you know nothing please shut up.

 

[yellowdonkey]

Fortunately I don't have the experience of being a patient in a pain clinic. But maybe compared with you I had a pain clinic. And please show me the data - maybe you remember EBM regarding the benefits of pain medicine . Nobody cares about your personal opinion you can post it on facebook - if you are a scientist is all about data. If you know nothing please shut up.

Haha okay scientist, "pill pushers" are the reason why you're crying on the Internet about a problem you don't seem to really know much about? Like I said, pain docs aren't the only ones giving out opioids, so whats your point?
Actually, I don't want to waste my time discussing with a loser who complains and points fingers online with that kind of attitude. If its eating you up that bad do something about it or try and convince your colleagues professionally. I doubt you are this bold in person.

Sent from my SM-N900V using SDN mobile

 

[Aether2000]

There is no doubt pain physicians have contributed mightily to the opioid epidemic. While primary care and orthopedics prescribe to the most patients and are responsible for most prescriptions, pain physicians provide patients with the highest doses of opioid- sometimes 10-20 times higher than the typical PCP prescribes. Unfortunately pain physicians (many of which early on never had formal training in pain medicine but were "grandfathered" in board certification) were snookered by Purdue Pharma who massively advertised to pain physicians that Oxycontin was less addictive than other opioids because of the sustained release mechanism (in the original package insert, approved by a FDA agent who subsequently became a Purdue employee), opioids had a low rate of addiction (extrapolated from acute pain studies), and that patients who appeared to be addicted simply needed more drug (pseudoaddiction). Purdue initiated these narratives that became self-sustaining talking points in their speakers and in the scientific literature. Of course the government did not help matters and neither did the quasi-governmental entities such as JCAHO or FSMB when they adopted policies that focused nurses and doctors on the treatment of pain. But even after all of this, when it became evident pain could not be controlled at the same level unless opioids were escalated to the point of patient oblivion in many patients, pain docs continued prescribing massive doses, eschewing the CDC warnings of massive deaths linked to opioid dosages. Many pain docs have curtailed prescribing or eliminated opioids, but some pain docs now run quid pro quo scams- giving opioids only to those receiving continued injections. Others prescribing opioids have purchased their own urine drug analyzers and run endless urine drug testing as an income source while some receive kickbacks from "genomic testing" (unproven to have any benefit at all).

The fact is, we now have over 20 studies showing reducing or eliminating opioids from chronic pain patients actually improves pain and function. This can mean only one thing: opioids are ineffective in chronic pain treatment, and what is perceived by pain patients to be effectiveness while taking the opioids is avoidance of withdrawal syndrome- no different than what is experienced by heroin addicts who only early on had euphoria: their purpose in continued use of heroin is to avoid the withdrawal syndrome.

Chronic opioid prescribing always begins with acute opioid prescribing, and surgeons and PCPs are being reigned in by state governments for overprescribing post operatively. However the idea that opioids are not needed post surgery and have not been proven to be any more effective than NSAIDs after some surgeries has escaped surgeons.

 

[Prometheus123]

There is no doubt pain physicians have contributed mightily to the opioid epidemic. While primary care and orthopedics prescribe to the most patients and are responsible for most prescriptions, pain physicians provide patients with the highest doses of opioid- sometimes 10-20 times higher than the typical PCP prescribes. Unfortunately pain physicians (many of which early on never had formal training in pain medicine but were "grandfathered" in board certification) were snookered by Purdue Pharma who massively advertised to pain physicians that Oxycontin was less addictive than other opioids because of the sustained release mechanism (in the original package insert, approved by a FDA agent who subsequently became a Purdue employee), opioids had a low rate of addiction (extrapolated from acute pain studies), and that patients who appeared to be addicted simply needed more drug (pseudoaddiction). Purdue initiated these narratives that became self-sustaining talking points in their speakers and in the scientific literature. Of course the government did not help matters and neither did the quasi-governmental entities such as JCAHO or FSMB when they adopted policies that focused nurses and doctors on the treatment of pain. But even after all of this, when it became evident pain could not be controlled at the same level unless opioids were escalated to the point of patient oblivion in many patients, pain docs continued prescribing massive doses, eschewing the CDC warnings of massive deaths linked to opioid dosages. Many pain docs have curtailed prescribing or eliminated opioids, but some pain docs now run quid pro quo scams- giving opioids only to those receiving continued injections. Others prescribing opioids have purchased their own urine drug analyzers and run endless urine drug testing as an income source while some receive kickbacks from "genomic testing" (unproven to have any benefit at all).

The fact is, we now have over 20 studies showing reducing or eliminating opioids from chronic pain patients actually improves pain and function. This can mean only one thing: opioids are ineffective in chronic pain treatment, and what is perceived by pain patients to be effectiveness while taking the opioids is avoidance of withdrawal syndrome- no different than what is experienced by heroin addicts who only early on had euphoria: their purpose in continued use of heroin is to avoid the withdrawal syndrome.

Chronic opioid prescribing always begins with acute opioid prescribing, and surgeons and PCPs are being reigned in by state governments for overprescribing post operatively. However the idea that opioids are not needed post surgery and have not been proven to be any more effective than NSAIDs after some surgeries has escaped surgeons.

Thanks for this. This post would make a great TED talk.

 

[2win]

There is no doubt pain physicians have contributed mightily to the opioid epidemic. While primary care and orthopedics prescribe to the most patients and are responsible for most prescriptions, pain physicians provide patients with the highest doses of opioid- sometimes 10-20 times higher than the typical PCP prescribes. Unfortunately pain physicians (many of which early on never had formal training in pain medicine but were "grandfathered" in board certification) were snookered by Purdue Pharma who massively advertised to pain physicians that Oxycontin was less addictive than other opioids because of the sustained release mechanism (in the original package insert, approved by a FDA agent who subsequently became a Purdue employee), opioids had a low rate of addiction (extrapolated from acute pain studies), and that patients who appeared to be addicted simply needed more drug (pseudoaddiction). Purdue initiated these narratives that became self-sustaining talking points in their speakers and in the scientific literature. Of course the government did not help matters and neither did the quasi-governmental entities such as JCAHO or FSMB when they adopted policies that focused nurses and doctors on the treatment of pain. But even after all of this, when it became evident pain could not be controlled at the same level unless opioids were escalated to the point of patient oblivion in many patients, pain docs continued prescribing massive doses, eschewing the CDC warnings of massive deaths linked to opioid dosages. Many pain docs have curtailed prescribing or eliminated opioids, but some pain docs now run quid pro quo scams- giving opioids only to those receiving continued injections. Others prescribing opioids have purchased their own urine drug analyzers and run endless urine drug testing as an income source while some receive kickbacks from "genomic testing" (unproven to have any benefit at all).

The fact is, we now have over 20 studies showing reducing or eliminating opioids from chronic pain patients actually improves pain and function. This can mean only one thing: opioids are ineffective in chronic pain treatment, and what is perceived by pain patients to be effectiveness while taking the opioids is avoidance of withdrawal syndrome- no different than what is experienced by heroin addicts who only early on had euphoria: their purpose in continued use of heroin is to avoid the withdrawal syndrome.

Chronic opioid prescribing always begins with acute opioid prescribing, and surgeons and PCPs are being reigned in by state governments for overprescribing post operatively. However the idea that opioids are not needed post surgery and have not been proven to be any more effective than NSAIDs after some surgeries has escaped surgeons.

I agree with you partially .
The point is the that none of the professional pain societies had a stand in time regarding the pain crisis.
And it is shameful - I question their integrity .
Could you also give us the RCT-s showing that interventional pain medicine improved quality of life and reduction in narcotics - long term ?
Appreciate and thank you .

 

[Maverikk]

I have to pull the reins on these horses. The pain population is unique and does require a skilled physician. Often times pcps, surgeons and hospital providers do over-prescribe. The incidence of physicians doing this knowingly is overblown on this thread. If you have a postop pt, an old Grannie who recently fell I can understand why they're getting prescribed opioids. The pain physicians I've worked with handle that segment who are beyond normal needs. Their goal is return to function, if that means a lot of oxy, an intrathecal catheter so be it; but it needs physicians whose goal is returning to baseline function when the PCP/surgeon is uncomfortable. Are there pain docs who are just after money sure, but liability wise it's not that common. The pain docs need to intervene earlier so the post-op hip who keeps requiring opioids gets seen before falling off.

 

[Aether2000]

There is not significant evidence interventional pain reduces opioid consumption long term. Unfortunately these patients should have never been started on opioids in the first place.

 

[Orin]

There are data suggestive of interventional technique's ability to reduce opioid consumption and improve function long term for some of our more durable interventions, but most injections are a temporizing/diagnostic maneuver in my opinion.

For example: Intrathecal Opioid Therapy for Non-Malignant Chronic Pain: A Long-Term Perspective. - PubMed - NCBI
Similar data are out there for stimulation, though intrathecal therapy is a great example of how we can reduce systemic opioid exposure, utilize novel agents, and improve QOL/function/pain.

Regardless, we're all dealing with the same **** show with opioids and I don't have the energy to fight about who caused it.

 

[Timeoutofmind]

I agree with you partially .
The point is the that none of the professional pain societies had a stand in time regarding the pain crisis.
And it is shameful - I question their integrity .
Could you also give us the RCT-s showing that interventional pain medicine improved quality of life and reduction in narcotics - long term ?
Appreciate and thank you .

There is a substantial medical evidence that opioids make chronic pain worse and not better.
So interventional pain techniques do not reduce opioid consumption.
Which is to say, decreasing people‘s level of pain does not reduce opioid consumption.
It might be a little bit hard to wrap your mind around, but basically the treatment of chronic pain is the treatment of chronic pain. Giving people opioids is giving people opioids. The two do not overlap. They are different questions with different considerations.

In answer to your second question. Spinal cord stimulation systems have level one evidence. Maybe start with the SENZA trial.

You might want to look at the recent paper published comparing intra-articular steroid injections in the knee versus cooled radio frequency ablation to the genicular nerves.

But your question is hopelessly broad. Maybe start with an ACGME pain fellowship.

 

[244913]

There is a substantial medical evidence that opioids make chronic pain worse and not better.
So interventional pain techniques do not reduce opioid consumption.
Which is to say, decreasing people‘s level of pain does not reduce opioid consumption.
It might be a little bit hard to wrap your mind around, but basically the treatment of chronic pain is the treatment of chronic pain. Giving people opioids it’s giving people opioids. The two do not overlap. They are different questions with different considerations.

In answer to your second question. Spinal cord stimulation systems have level one evidence. Maybe start with the SENZA trial.

You might want to look at the recent paper published comparing intra-articular steroid injections in the knee versus cooled radio frequency ablation to the genicular nerves.

But your question is hopelessly broad. Maybe start with an ACGME pain fellowship.

The pain physician of tomorrow can make the greatest impact by choosing good candidates for selected interventions, not starting young, non-working patients on opioids when they are inevitably punted to you within the group or health system, and weaning down to low dose ( < 40 MME) any patients you inherit who have been started on them. It goes without saying that any patient, regardless of age, should be weaned off completely if they do not demonstrate functional improvement etc. or have any aberrancy.

This is necessarily difficult work, and demands doctors with a strong moral compass. I think the pills for shots model (MD + NP/PA) should come to an end. Pill mills are closing.

Pain as a whole probably needs to be less interventional and more focused on harm reduction. In my short time in practice I have seen suboxone make a huge difference. It saves lives.

Harm reduction pays huge societal dividends.

- ex 61N

 

[anbuitachi]

When it is the time to recognize that pain medicine is a total failure? What is the contribution of the pain management field in the opioid epidemic? Just have the balls to recognize that is useless . You want facts? What's the percentage of patient post interventional procedures without opioids and productive? Just spit it on "pain doctors"!

I dont have a lot of experience in pain but i dont think non pain docs here do either. But in my couple months of rotating thru pain , they do mostly interventions and rare give opioids in the place i was at. THe patients were all thankful people. they loved the pain doc who did procedures on them. His notes were very detailed, it seems like the injections/blocks help way more often than not. I think it's a great field, helping people where other people cant help.

 

[244913]

There is not significant evidence interventional pain reduces opioid consumption long term. Unfortunately these patients should have never been started on opioids in the first place.

Very true. Interventional procedures work much better in opioid naive patients. Especially neuromodulation.

- ex 61N

 

[Hoya11]

Very true. Interventional procedures work much better in opioid naive patients. Especially neuromodulation.

- ex 61N

IME there are not many patients (i cant think of any) with a SCS who are not also on opiates. Neuromodulation is a cure for very few, a mild benefit for some in the context of other pain meds, and not helpful at all to many

 

[Orin]

IME there are not many patients (i cant think of any) with a SCS who are not also on opiates. Neuromodulation is a cure for very few, a mild benefit for some in the context of other pain meds, and not helpful at all to many

Part of that is mentality with them, but that doesn't hold true though for the non-electrical neuromodulation with intrathecal pumps, as most folks are now going to low dose opioid monotherapy where the patients are taken completely off of systemic opioids.

 

[244913]

Part of that is mentality with them, but that doesn't hold true though for the non-electrical neuromodulation with intrathecal pumps, as most folks are now going to low dose opioid monotherapy where the patients are taken completely off of systemic opioids.

Who is putting people on low dose IT therapy routinely these days? Sounds like a disaster. I hate pumps and I resent the charlatans who put them in (even "low dose") and then move to a different state a year later so the patient ends up on your doorstep with their pump empty and alarming. Not to mention the surgical complications, MRI re-programs, catheter problems...Putting pumps in people these days for non cancer pain is akin to painting a scarlet letter on their chest. No other practitioner will want anything to do with them.

I'd much rather have somebody on 30 oral MME's then a morphine monotherapy pump at 300 mcg a day. The newer generation medications for constipation in my mind have obviated the old excuses for implantation in the elderly.

Good riddance to pumps for non cancer pain.

- ex 61N

 

[244913]

IME there are not many patients (i cant think of any) with a SCS who are not also on opiates. Neuromodulation is a cure for very few, a mild benefit for some in the context of other pain meds, and not helpful at all to many

In the private practice (pills for shots) model, I agree you won't find many SCS candidates not on moderate to high dose opioids. How does the algorithm go? Percocet 10/325 QID (the "carrot") ---> MBB's x 2 --> failed RFA ---> series of 3 bilateral 3 level TFESI's --> discogram ---> repeat ESI's with PRP x 2 ---> Percocet 10/325 q4h prn ---> surgical referral ---> 4 level fusion --> Oxycontin BID and percocet 10/325 q4h prn---> Back to you for SCS trial---> SCS implant ---> IT pump ---> kick out of practice because "insurance changed." ***All blocks done under sedation with CRNA's in practice owned ASC *** ***Worker's comp patients done in hospital surgicenter***

My practice is different- I know you're a skeptic- but 90% of my SCS trial patients are opioid naive and I don't implant pumps for non cancer pain.

- ex 61N

 

[Orin]

Who is putting people on low dose IT therapy routinely these days? Sounds like a disaster. I hate pumps and I resent the charlatans who put them in (even "low dose") and then move to a different state a year later so the patient ends up on your doorstep with their pump empty and alarming. Not to mention the surgical complications, MRI re-programs, catheter problems...Putting pumps in people these days for non cancer pain is akin to painting a scarlet letter on their chest. No other practitioner will want anything to do with them.

I'd much rather have somebody on 30 oral MME's then a morphine monotherapy pump at 300 mcg a day. The newer generation medications for constipation in my mind have obviated the old excuses for implantation in the elderly.

Good riddance to pumps for non cancer pain.

- ex 61N

Agree with pumps being difficult and people having done some screwed up stuff with them when you were paid by the dose, etc.
Agree they're surgically more challenging.
Agree that I'd rather do 30 oral MMEs than a pump, but disagree as analgesia, function, QOL are better with the pump for certain patients with microdose.

Trialing and Maintenance Dosing Using a Low-Dose Intrathecal Opioid Method for Chronic Nonmalignant Pain: A Prospective 36-Month Study. - PubMed - NCBI

And that's not even considering ziconotide if you can afford it.

When you cross a therapeutic modality off the list, you must have great skills/outcomes or I must assume it's more about the ease/risk for the practice/practitioner than the risk/benefit for the patient.

 

[powermd]

My first year out in practice I worked for a place that seemed to follow a pills-for-injections model. My contract was not renewed because I was too conservative with opiates. Not a problem, I hated it there. Been non-narcotic 100% interventional for 7 years now. Totally different patient population- they don't want drugs, and just want to get better. It's a very rewarding way to practice. I don't have a RCT for you, but I hear from patients every day "thank God you guys exist" and "you don't know how much you've helped me". I can't say they're not all placebo responders, but I can say their gratitude has nothing to do with Percocet 10/325.

 

[244913]

My first year out in practice I worked for a place that seemed to follow a pills-for-injections model. My contract was not renewed because I was too conservative with opiates. Not a problem, I hated it there. Been non-narcotic 100% interventional for 7 years now. Totally different patient population- they don't want drugs, and just want to get better. It's a very rewarding way to practice. I don't have a RCT for you, but I hear from patients every day "thank God you guys exist" and "you don't know how much you've helped me". I can't say they're not all placebo responders, but I can say their gratitude has nothing to do with Percocet 10/325.

That's fantastic. Pain can be the best job in medicine when opioids are out of the picture. These patients also really do well IME with all manner of interventions. Congrats on having such an ethical and well managed practice.

- ex 61N

 

[pgg]

In the private practice (pills for shots) model, I agree you won't find many SCS candidates not on moderate to high dose opioids. How does the algorithm go? Percocet 10/325 QID (the "carrot") ---> MBB's x 2 --> failed RFA ---> series of 3 bilateral 3 level TFESI's --> discogram ---> repeat ESI's with PRP x 2 ---> Percocet 10/325 q4h prn ---> surgical referral ---> 4 level fusion --> Oxycontin BID and percocet 10/325 q4h prn---> Back to you for SCS trial---> SCS implant ---> IT pump ---> kick out of practice because "insurance changed." ***All blocks done under sedation with CRNA's in practice owned ASC *** ***Worker's comp patients done in hospital surgicenter***

That's horrifying.

 

[nimbus]

That's horrifying.

A total s***show....but the norm in some places

 

[Timeoutofmind]

IME there are not many patients (i cant think of any) with a SCS who are not also on opiates. Neuromodulation is a cure for very few, a mild benefit for some in the context of other pain meds, and not helpful at all to many

I do a lot of SCS and DRG. A lot. I don’t do chronic opioids. The patients do great. I have had two trials that didn’t go to permanent. I have had to permanents that aren’t happy with the amount of pain relief . That’s it.

Did one last week for a lady with necrosis of all of her pelvic bones and severe femoral nerve injury from radiation for a retroperitoneal sarcoma. Pain went from 8 to 2/10.

 

[Timeoutofmind]

My first year out in practice I worked for a place that seemed to follow a pills-for-injections model. My contract was not renewed because I was too conservative with opiates. Not a problem, I hated it there. Been non-narcotic 100% interventional for 7 years now. Totally different patient population- they don't want drugs, and just want to get better. It's a very rewarding way to practice. I don't have a RCT for you, but I hear from patients every day "thank God you guys exist" and "you don't know how much you've helped me". I can't say they're not all placebo responders, but I can say their gratitude has nothing to do with Percocet 10/325.

What’s ur practice setting?

 

[Hoya11]

Part of that is mentality with them, but that doesn't hold true though for the non-electrical neuromodulation with intrathecal pumps, as most folks are now going to low dose opioid monotherapy where the patients are taken completely off of systemic opioids.

LOL. pumps are a crime... maybe your experience is just way different from mine.. i saw pumps go in for very silly reasons, and very few patients come off other opiates when the pump went in

 

[powermd]

What’s ur practice setting?

Community private practice in a semi-rural area.

 

[epidural man]

When it is the time to recognize that pain medicine is a total failure? What is the contribution of the pain management field in the opioid epidemic? Just have the balls to recognize that is useless . You want facts? What's the percentage of patient post interventional procedures without opioids and productive? Just spit it on "pain doctors"!

Here’s the truth not anyone is willing to admit or believe.

We don’t have an opioid problem in this country. We have a chronic pain problem. Opioids are just a manifestation of that problem.

From 2000 to 2010, US population has grown 9%. Chronic pain sufferes grew 122%.

That’s the real question. Why is chronic pain such an issue? Hint: we don’t really have a chronic pain problem - we have an overworked, over stressed, mentally very unhealthy pollution.

 

[medking]

Pain, especially chronic pain, is such a fascinating field. We need clinicians good at the art of medicine. Choosing the appropriate therapy for each patient takes experience and good clinical judgment. Whether it is pharmacologic intervention, injections, physical/cognitive therapy, or more interventional procedures, patient selection and timing is key.

The opioid crisis is also fascinating. Like the previous person mentioned, our society and culture definitely play a role in all of this. Instant gratification is a real thing in this country. There is a reason why the US consumes a ton of opioids compared to other countries in the world. The more I delve into medicine, the more I find it’s not just about medicine.

 

[powermd]

Here’s the truth not anyone is willing to admit or believe.
We don’t have an opioid problem in this country. We have a chronic pain problem. Opioids are just a manifestation of that problem.

I would disagree. The problem is much bigger, and has nothing to do with chronic pain per se.

It's a chemical coping problem, and it's existed as long as "candy" has existed that helps alleviate unpleasant sensations. Take your pick- opiates, benzos, muscle relaxants, recreational drugs. Might even include caffeine and sugar.

Chemical coping is part of America's culture. The chemical in question is incidental.

 

[Machinery]

Your rant is true of many specialties treating chronic conditions.

When it is the time to recognize that pain medicine is a total failure? What is the contribution of the pain management field in the opioid epidemic? Just have the balls to recognize that is useless . You want facts? What's the percentage of patient post interventional procedures without opioids and productive? Just spit it on "pain doctors"!

 

[Machinery]

Managing chronic pain is tough. Not my thing but someone has to do it. OP, do you have any better ideas on how to treat chronic pain or are you just doing the easy specialty bashing thing?

 

[mwa]

I hate to overly simplify things, but it's a problem of incentives:

Interventionalists get paid to perform interventions. Let's be generous and say that they have more than one size of hammer in their toolbox; still, every problem looks like a nail.

Patients want interventions, and they don't have to pay for them. Some like them because it proves to naysayers in their social groups that the pain isn't all in their head, that they don't have just run-of-the-mill back pain. After all, if a doctor "sees something on imaging" then it's real. Some like interventions because they help their disability case or their lawsuits. Some agree to interventions because they think that undergoing interventions will lead to opiate prescriptions. Some like interventions because they get out of the house, get doped up on versed/fentanyl/propofol, get attention from cute young nurses, and now have doctor's orders to go home and do nothing at all--so there should be no surprise that they feel mildly better the next day.

ASCs and hospitals love interventions because the checks clear.

I don't think that all pain interventions are snake oil, but I do think that something like 90% probably are. What a fantastic scam, though: target something that everybody at one time or another will experience, that can't be objectively measured, that in the vast, vast, vast majority of times will resolve on its own. In the cases when your interventions have bought enough time for the pain to run its course, you take all the credit. In the cases where the pain persists, you check your list of handsomely-compensated interventions, and suggest something more expensive. Rinse and repeat. And, when you run out of tricks and the patient is still in pain, you simply shrug your shoulders and point out that there's a new sucker in your waiting room, so you'll be moving on.

I'm reminded of the words of Upton Sinclair:
“It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

 

[nimbus]

.

 

[nimbus]

.

 

[powermd]

You are posting to a board frequented by a lot of 100% pain specialists.

Have you earned any authority to make claims like:

* 90% of pain interventions are snake oil?
* Every problem looks like a nail (to pain specialists).
* The vast, vast, vast majority of chronic pain problems (seen by pain specialists) resolve on their own.

You correctly identify that patients may have secondary gain issues, and doctors, ASCs, and hospitals like getting paid for their work.

A confluence of interest does not a conflict make. I said that.

Do you believe that a majority of us practicing pain medicine are basically rapists exploiting the system? If so, how do you feel about this behavior among other medical specialists?

I hate to overly simplify things, but it's a problem of incentives:

Interventionalists get paid to perform interventions. Let's be generous and say that they have more than one size of hammer in their toolbox; still, every problem looks like a nail.

Patients want interventions, and they don't have to pay for them. Some like them because it proves to naysayers in their social groups that the pain isn't all in their head, that they don't have just run-of-the-mill back pain. After all, if a doctor "sees something on imaging" then it's real. Some like interventions because they help their disability case or their lawsuits. Some agree to interventions because they think that undergoing interventions will lead to opiate prescriptions. Some like interventions because they get out of the house, get doped up on versed/fentanyl/propofol, get attention from cute young nurses, and now have doctor's orders to go home and do nothing at all--so there should be no surprise that they feel mildly better the next day.

ASCs and hospitals love interventions because the checks clear.

I don't think that all pain interventions are snake oil, but I do think that something like 90% probably are. What a fantastic scam, though: target something that everybody at one time or another will experience, that can't be objectively measured, that in the vast, vast, vast majority of times will resolve on its own. In the cases when your interventions have bought enough time for the pain to run its course, you take all the credit. In the cases where the pain persists, you check your list of handsomely-compensated interventions, and suggest something more expensive. Rinse and repeat. And, when you run out of tricks and the patient is still in pain, you simply shrug your shoulders and point out that there's a new sucker in your waiting room, so you'll be moving on.

I'm reminded of the words of Upton Sinclair:
“It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

 

[Hoya11]

You are posting to a board frequented by a lot of 100% pain specialists.

Have you earned any authority to make claims like:

* 90% of pain interventions are snake oil?
* Every problem looks like a nail (to pain specialists).
* The vast, vast, vast majority of chronic pain problems (seen by pain specialists) resolve on their own.

You correctly identify that patients may have secondary gain issues, and doctors, ASCs, and hospitals like getting paid for their work.

A confluence of interest does not a conflict make. I said that.

Do you believe that a majority of us practicing pain medicine are basically rapists exploiting the system? If so, how do you feel about this behavior among other medical specialists?

can you refute his claims? other than saying he is not a pain doc so he doesnt know..

dont you find it interesting that these threads/feelings/ideas keep popping up about pain? not peds/cv/anything else

what other medical specialists do you believe have a similar situation? what behavior do you find similar?

 

[Orin]

I hate to overly simplify things, but it's a problem of incentives:

Interventionalists get paid to perform interventions.

Again, as anesthesiologists, remind me of the anesthetics we have refused to perform for cases because they're not indicated or supported by evidence for improving function or quality of life?

I assume we're all trying to help people/patients. Some of us just have evidence that our help is actually helping, while others are still in the dark.

Pain's the most complex "vital sign" to help with. It's the easiest to bash on since most everyone treats it, so much like fecal orifices, everyone has the best way to do it.

Granted, we've been doing it wrong for a long time.

 

[Hoya11]

Again, as anesthesiologists, remind me of the anesthetics we have refused to perform for cases because they're not indicated or supported by evidence for improving function or quality of life?

I assume we're all trying to help people/patients. Some of us just have evidence that our help is actually helping, while others are still in the dark.

Pain's the most complex "vital sign" to help with. It's the easiest to bash on since most everyone treats it, so much like fecal orifices, everyone has the best way to do it.

Granted, we've been doing it wrong for a long time.

i have heard this argument before,

do you not think it is different to:

give anesthesia for a procedure suggested by a surgeon and agreed to by the patient

vs

actually suggest the procedure for the patient

i do. i think its more egregious to actually do the procedure and more forgiveable to simply provide the sedation for the procedure that has already been agreed upon/sold

tldr: i dont think that because we provide sedation for BS cases it makes us as fallable as those who suggest and book and do the BS procedure

 

[244913]

i have heard this argument before,

do you not think it is different to:

give anesthesia for a procedure suggested by a surgeon and agreed to by the patient

vs

actually suggest the procedure for the patient

i do. i think its more egregious to actually do the procedure and more forgiveable to simply provide the sedation for the procedure that has already been agreed upon/sold

tldr: i dont think that because we provide sedation for BS cases it makes us as fallable as those who suggest and book and do the BS procedure

I think certain procedures- carefully selected- help well selected patients

Some patients get better on their own.

Having come from a very interventionally focused fellowship, in my current practice I sometimes get more pleasure from talking patients out of procedures than doing them. Pain specialists can make a big difference by practicing harm reduction strategies- this redounds to society's benefit.

I think that to be a good pain specialist you must have a strong moral compass. There are a lot of folks out there who have done/are doing the wrong thing with opioids and poorly selected interventions.

I've been very impressed by the posters on the pain forum, and those who frequent this board. I don't think they represent the PP norm, but maybe one day they will.

- ex 61N

 

[Orin]

i think its more egregious to actually do the procedure and more forgiveable to simply provide the sedation for the procedure that has already been agreed upon/sold

tldr: i dont think that because we provide sedation for BS cases it makes us as fallable as those who suggest and book and do the BS procedure

The sin of omission versus commission? As a surgeon once reminded me, the patient didn't come to the hospital for an anesthetic, so I suppose that's a fair argument. If you're arguing that though, I would say you've got no basis for being part of the discussion since you're not willing to make or take part in that critical decision.

The chronic pain folks are desperate. A lot of folks make bank off that, including the anesthesiologists, surgeons, ASCs, etc. I've got no problems with a provider trying to help someone, but the risk/benefit balance to interventions(surgeries, procedures, consultations, or medications) needs to be addressed and you've got to have a strong sense of the patient's goals instead of your wallet.

At the end of the day though, sometimes you just need a better placebo and in that scenario the used car/snake oil salesmen are great until they cause harm.

 

[powermd]

can you refute his claims? other than saying he is not a pain doc so he doesnt know..

dont you find it interesting that these threads/feelings/ideas keep popping up about pain? not peds/cv/anything else

what other medical specialists do you believe have a similar situation? what behavior do you find similar?

It's not my job to refute his claims. He brought them up, it's on him to add credibility.

Would I not be open to criticism were I to assert that physician level anesthesia training is superfluous in 90% of anesthetics? Proof that I'm wrong is hard to come by. Does that mean I'm right?

Why has pain been under the microscope lately? Hmmm... must be the NSAID epidemic.

 

[mwa]

powermd would probably be interested to learn that I did just over three months in a ACGME-accredited Pain Fellowship before I realized what a wholesale scam it is (and left for private practice). Sure, that makes me both a slow learner (to have needed three months to see what most anesthesiologists realize with only a couple of weeks' exposure during residency) and a much faster learner than folks like powermd who have yet to figure it out.

That somebody else in medicine is just as bad or worse (What about chiropractors?! What about spine surgeons?! What about charlatans selling PRP or stem cell therapy?! or lasers?! or robots?! or...) doesn't mean that pain specialists get a pass.

If the steroid injections get people back to work or reduce opiate consumption it should be pretty easy to show, especially considering how many millions of dollars hang in the balance. The lack of good evidence (Almost twice as good as placebo? Really? Almost twice as good as nothing at all?? Or is it because the placebo injections still--as was once the apologists' theory--"flush away substance P?") is pretty damning.

When a pain interventionalist can make a go of it charging cash for his procedures and offering a money back guarantee if the patient is not satisfied, then I will agree there might be something to it. Show me that interventionalist who succeeds in selling his services directly to a patient without a third party picking up the tab, and then I'll do a recent literature search in hopes of "adding credibility."