give me "Pain medicine"

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
M

med7343

Full Member
5+ Year Member
Joined
Dec 16, 2018
Messages
49
Reaction score
17
Getting a little frustrated of patient being referred for pain medicine- especially with the ones with history of substance abuse in the past.
Agitated and angry patients especially when i say I cant .....
Whats the best way to have and a safe practice and avoid being killed by someone
Any tips?
Members don't see this ad.
 
What is your screening process? I review all incoming referrals. If it’s for opioids I flat out reject especially if it’s clear they are just drug seekers. For self-referrals the new patient coordinators are instructed to tell patients I don’t prescribe opioids.
If you aren’t in a position to be able to screen your referrals (hospital-employed and they make you see them all, or something like that) you can at least set up policies of noRx at first visit, UDS and risk stratification required at first visit, and having your staff call all patients and tell them those policies and offer them a chance to cancel.
 
med7343 said:
Getting a little frustrated of patient being referred for pain medicine- especially with the ones with history of substance abuse in the past.
Agitated and angry patients especially when i say I cant .....
Whats the best way to have and a safe practice and avoid being killed by someone
Any tips?
Click to expand...
Pick up the phone and Tell those referring docs to stop sending you those kind of referrals
 
Members don't see this ad :)
painfree23 said:
What happens when they say, "but you are a ''pain doctor''?"
Click to expand...
Then you explain to the current research on opioids for chronic pain, and why it’s not an appropriate treatment for many patients. If you don’t do any opioid management you can borrow my line: “I don’t recommend or prescribe opioids for chronic pain.” That lets them know both that you won’t be taking it on, and that you won’t throw it back on the PCP either. If you do judicious prescribing then you need to educate your referring providers and make sure they know not to tell patients to just come to you for a script - there will be discussion and risk stratification, and trial of alternatives.
 
I’ve run into this issue as well. What do you all recommend to someone like me who is in a solo private practice in an area that is dominated by hospital employed docs who reluctantly refer out? The hospital employed pain physician doesn’t prescribe opioids but the pcp’s in the area are fairly generous. While I never do anything I’m uncomfortable with, juggling pcp satisfaction and patient safety can be very difficult
 
“It’s not you, it’s me.” Don’t put them on the defensive. I explain nicely that I’m not equipped to manage their issues and I’m not comfortable trying. I don’t comment on whether or not they have pain. It helps if there are several other pain physicians in the area.
 
pmrmd said:
Probably the most spoken words in all womandom. If I had a nickel...
Click to expand...

Case in point: women use this strategy all the time to avoid angry men lashing out when they’re rejected and preserve hurt feelings.
 
lobelsteve said:
A guy evaded my screening and seen this AM. 1 hour after my post above I got to use both phrases and just get up and walk out of exam room.
Daily meth/THC abuse and asked for Tyl 3 6x in 5 min.
Bye Felicia (not his real name)
Click to expand...

My anxiety is not saying no and leaving the room. It is of a crazy person making a scene in the waiting room and getting a good new patient nervous about what goes on. Or writing a negative online review and dissuading good people from scheduling w/me. That sort of thing.
 
paindoc007 said:
My anxiety is not saying no and leaving the room. It is of a crazy person making a scene in the waiting room and getting a good new patient nervous about what goes on. Or writing a negative online review and dissuading good people from scheduling w/me. That sort of thing.
Click to expand...
Abusers have their own community. Word will spread you aren’t a soft touch, and you will have fewer of them scheduling with you. Go ahead and take a few knocks on your online reviews - invest in a platform that helps generate positive reviews and it will drown them out. Much better that route than being free and easy with the opioids - do that and soon you will have nothing but med check appointments, and it goes much worse telling them you are cutting off their pills after a bad UDS than telling them no the first time you see them.
 
Members don't see this ad :)
med7343 said:
Getting a little frustrated of patient being referred for pain medicine- especially with the ones with history of substance abuse in the past.
Agitated and angry patients especially when i say I cant .....
Whats the best way to have and a safe practice and avoid being killed by someone
Any tips?
Click to expand...


Need a screening process of some sort. Many ways to do it, some of which can add extra work for the staff.
Cost of doing business in this specialty for private practice.
 
smarterchild said:
I’ve run into this issue as well. What do you all recommend to someone like me who is in a solo private practice in an area that is dominated by hospital employed docs who reluctantly refer out? The hospital employed pain physician doesn’t prescribe opioids but the pcp’s in the area are fairly generous. While I never do anything I’m uncomfortable with, juggling pcp satisfaction and patient safety can be very difficult
Click to expand...

Over time you will realize whom will send you good/decent referrals and whom will just send you dumps. I would recommend trying to have a marketing lunch with referring sources so you can meet face to face and discuss how you can help them. You can make a good connection and use that opportunity to set realistic expectations. If they just want to dump patients on you after their pain guy is done with them, then tell them you expect them to manage after. I let people know this at lunches all of the time and they usually understand my position as not being just "the med guy." If Dr. X is your go to for spine pain, then Dr. X should manage everything associated with that issue including meds. If they won't and the pcp knows that, then don't send these patients to Dr. X. Also get an idea of what the hospital pain people do. A lot of the ones in my area don't do RF, SCS and other moderate to advanced procedures, so we actually get some good referrals from them. Review all referrals. If you don't think you can help just say you can't see them. Consults don't pay enough to make it worth getting screamed at. It will take longer to get busy, but you will be happier.
 
med7343 said:
Getting a little frustrated of patient being referred for pain medicine- especially with the ones with history of substance abuse in the past.
Agitated and angry patients especially when i say I cant .....
Whats the best way to have and a safe practice and avoid being killed by someone
Any tips?
Click to expand...
I don’t know that there is ever a case where there isn’t a non-opioid medication Or Non pharmaceutical intervention that i can Offer that hasn’t been tried before. I document what i offered, For example gabapentin (or other non opioid), PT or home exercise print out, tens unit, topicals, interventional procedures, reimaging, etc, psych referral. i document usually like 3-4 options that i offer and the patient refused these and is repeatedly asking for opioids only and sepcifically drug xyz. Make sure to tell referring that this patient is not a candidate for opioids due to this.

then i Immediately call The referring and repeat this same spiel. That way the Referring hears the truth from me first. Before the patient bad mouths and lies about me. “He only offered shots, etc.”
usually the referring knew the patient was a drug seeker but felt some kind of duty to refer out. I apologize that i can’t help on this one, but would be happy to see another patient.

this way the referring knows that you are no nonsense, you offer multiple tx options, and are diligent. Most people don’t call them in this situation.

having said above I do screen the heck out of every patient, but some slip through the cracks. This is how I handle the slip throughs.
 
paindoc007 said:
My anxiety is not saying no and leaving the room. It is of a crazy person making a scene in the waiting room and getting a good new patient nervous about what goes on. Or writing a negative online review and dissuading good people from scheduling w/me. That sort of thing.
Click to expand...

I deflect blame a lot. I tell them I understand and it’s really hard for people with pain these days, and that the government has made it impossible etc etc.
 
geauxg8rs said:
I don’t know that there is ever a case where there isn’t a non-opioid medication Or Non pharmaceutical intervention that i can Offer that hasn’t been tried before. I document what i offered, For example gabapentin (or other non opioid), PT or home exercise print out, tens unit, topicals, interventional procedures, reimaging, etc, psych referral. i document usually like 3-4 options that i offer and the patient refused these and is repeatedly asking for opioids only and sepcifically drug xyz. Make sure to tell referring that this patient is not a candidate for opioids due to this.

then i Immediately call The referring and repeat this same spiel. That way the Referring hears the truth from me first. Before the patient bad mouths and lies about me. “He only offered shots, etc.”
usually the referring knew the patient was a drug seeker but felt some kind of duty to refer out. I apologize that i can’t help on this one, but would be happy to see another patient.

this way the referring knows that you are no nonsense, you offer multiple tx options, and are diligent. Most people don’t call them in this situation.

having said above I do screen the heck out of every patient, but some slip through the cracks. This is how I handle the slip throughs.
Click to expand...

The reason u tell the referring doctor that they aren’t a candidate for opiates is because that’s all the patient asked for?
 
painfree23 said:
The reason u tell the referring doctor that they aren’t a candidate for opiates is because that’s all the patient asked for?
Click to expand...
Among others. If someone comes in refusing all Other treatments except for a specific opioid then that is drug seeking behavior and not a good candidate for opioids
 
Agast said:
Case in point: women use this strategy all the time to avoid angry men lashing out when they’re rejected and preserve hurt feelings.
Click to expand...
oh wow.... when I used to ask women out on dates, they would say "No thanks. oh and its not me, its you."




with regards to opioid seekers, you could do what I do on this forum.

start quoting studies and talking (patients say "drone incessantly") about the latest data and EBM regarding opioids. include practice guidelines established by "the system" that non-malignant pain is not treated by opioids, etc. blame the CDC if necessary...

eventually, most people get so bored they 1. fall asleep 2. decide it isn't worth their time and decide to listen to other options or 3. get so infuriated they storm out and never come back.
 
Ducttape said:
oh wow.... when I used to ask women out on dates, they would say "No thanks. oh and its not me, its you."




with regards to opioid seekers, you could do what I do on this forum.

start quoting studies and talking (patients say "drone incessantly") about the latest data and EBM regarding opioids. include practice guidelines established by "the system" that non-malignant pain is not treated by opioids, etc. blame the CDC if necessary...

eventually, most people get so bored they 1. fall asleep 2. decide it isn't worth their time and decide to listen to other options or 3. get so infuriated they storm out and never come back.
Click to expand...

And then when you are done they stare up at you and ask for pain medication.
 
You cannot fix this unless you screen all your patients. Who screens your new patients? What criteria do they look for? If you take "all comers" you are doomed.
 
a receptionist looks at the chart(not in detail though)
they look at PMP
Obviously not doing a good job- any other things to look out for apart from chart and PMP?
Thanks
 
med7343 said:
a receptionist looks at the chart(not in detail though)
they look at PMP
Obviously not doing a good job- any other things to look out for apart from chart and PMP?
Thanks
Click to expand...
Review charts yourself and decide. Maybe if someone has been with you a long time they could learn to spot the red flags, but there’s really no substitute for reviewing them yourself.
 
med7343 said:
a receptionist looks at the chart(not in detail though)
they look at PMP
Obviously not doing a good job- any other things to look out for apart from chart and PMP?
Thanks
Click to expand...

Just have them show you the PMP.

No meds on it? Schedule right away.

Some tramadol? 20-30 Norco/month? Schedule but obtain records prior to visit.

Oxy, Soma, Methadone, Xanax, etc? Red light. Needs substantial records and secondary review.
 
med7343 said:
a receptionist looks at the chart(not in detail though)
they look at PMP
Obviously not doing a good job- any other things to look out for apart from chart and PMP?
Thanks
Click to expand...

Its very simple:

Dr. med7343 does not prescribe opioids and will not be refilling any of your medications. Do you understand?

This is told at time of first contact before they fill out an intake and told again when the patient is roomed.
 
Ligament said:
Its very simple:

Dr. med7343 does not prescribe opioids and will not be refilling any of your medications. Do you understand?

This is told at time of first contact before they fill out an intake and told again when the patient is roomed.
Click to expand...
I’ve tried this but patients felt like they were being treated as drug abusers. Legit patients who just want injections would get the spchiel too and felt that way. Instead my front desk now says something along the lines of “this is an interventional pain clinic, we treat with injections/PT etc.” the drug seekers hang up before they finish the statement
 
med7343 said:
a receptionist looks at the chart(not in detail though)
they look at PMP
Obviously not doing a good job- any other things to look out for apart from chart and PMP?
Thanks
Click to expand...

Fibromyalgia, anxiety, depression, has had procedures and PT but they never work, obesity, disability, still smoking with copd, alcohol or drug history, already on opioids these and many other clues can be found in the records sent with the referral. And the ever present “medication management”.. each case is different and you really have to look at referrals individually to form an image. This is where your office staff will fail you.
 
Last edited:
painfree23 said:
I’ve tried this but patients felt like they were being treated as drug abusers. Legit patients who just want injections would get the spchiel too and felt that way. Instead my front desk now says something along the lines of “this is an interventional pain clinic, we treat with injections/PT etc.” the drug seekers hang up before they finish the statement
Click to expand...

Yes. Takes some work and has to be done tactfully. Can’t speak to every patient the same way.
 
Disciple said:
Yes. Takes some work and has to be done tactfully. Can’t speak to every patient the same way.
Click to expand...
Agreed. Is there a law against denying patient from seeing you for an initial visit (let’s say u review records or PDMP , can u deny the patient from coming into ur practice (legally))?
 
No actual law that I’m aware of. Usually works out best if you politely tell them ahead of time that in all likelihood you will not be able to continue their current regimen, or in some cases, prescribe them any controlled substances at all.
 
painfree23 said:
Agreed. Is there a law against denying patient from seeing you for an initial visit (let’s say u review records or PDMP , can u deny the patient from coming into ur practice (legally))?
Click to expand...
If you explicitly reject the referral because they are on opioids or looking for opioids, they might be able to sue for discrimination under ADA. Not saying they’d win but I think I remember reading about such a case in a prior thread.
 
callmeanesthesia said:
If you explicitly reject the referral because they are on opioids or looking for opioids, they might be able to sue for discrimination under ADA. Not saying they’d win but I think I remember reading about such a case in a prior thread.
Click to expand...

Being on opiates is a protected class? NOPE
 
callmeanesthesia said:
If you explicitly reject the referral because they are on opioids or looking for opioids, they might be able to sue for discrimination under ADA. Not saying they’d win but I think I remember reading about such a case in a prior thread.
Click to expand...

Yeah I remember it, There was some case against primary care physicians not accepting pts due to hx of opioid use. But as specialists I’d hope we’d be different
 
paindoc007 said:
Yeah I remember it, There was some case against primary care physicians not accepting pts due to hx of opioid use. But as specialists I’d hope we’d be different
Click to expand...

So what are most people doing?
 
Let them come in. You just have to do the screen and let them know in advance if you may not be prescribing opioids to them or may be changing their regimen. That will prevent the situation that develops in your office.

You basically need two crucial pieces of information.

1. Is there an inappropriate opioid regimen on board?

2. Is there an expectation that you will assume management of that regimen?
 
Disciple said:
Let them come in. You just have to do the screen and let them know in advance if you may not be prescribing opioids to them or may be changing their regimen. That will prevent the situation that develops in your office.

You basically need two crucial pieces of information.

1. Is there an inappropriate opioid regimen on board?

2. Is there an expectation that you will assume management of that regimen?
Click to expand...

I tried that for sometime. Patients still think they can convince me and then say they wasted their time coming to the office
 
painfree23 said:
So what are most people doing?
Click to expand...
For primary care we can’t refuse to see them due to history of opiate use or abuse but we can say we do not write prescriptions for those substances for new patients. (I think I’ve had a few that missed getting screened through and came in who are elderly and only on ambien or one person was on 30 pills of tramadol a year). I will refer them out if needed and I will happily manage their diabetes and htn. We can’t refuse to fare for patient but we do not have to write the prescriptions they demand. I think it’s fair to tell them that prior to a visit. We don’t have anyone closer than a 45 min drive that will write prescriptions for opiates. I have a long speech I do about how just opiates are not the appropriate treatment and I’ve had multiple patients who were very annoyed when I sent them to pain management who are now extremely thankful because they feel like they’ve gotten their lives back. They are typically treated with combination of injections, some with low dose opiates and muscle relaxers.
 
Keona said:
For primary care we can’t refuse to see them due to history of opiate use or abuse but we can say we do not write prescriptions for those substances for new patients. (I think I’ve had a few that missed getting screened through and came in who are elderly and only on ambien or one person was on 30 pills of tramadol a year). I will refer them out if needed and I will happily manage their diabetes and htn. We can’t refuse to fare for patient but we do not have to write the prescriptions they demand. I think it’s fair to tell them that prior to a visit. We don’t have anyone closer than a 45 min drive that will write prescriptions for opiates. I have a long speech I do about how just opiates are not the appropriate treatment and I’ve had multiple patients who were very annoyed when I sent them to pain management who are now extremely thankful because they feel like they’ve gotten their lives back. They are typically treated with combination of injections, some with low dose opiates and muscle relaxers.
Click to expand...

Do you have certain pain mgmt specialists that refuse to take on any such patients on pre-existing opioid regimens? If so, what are your perceptions on that as a primary care provider?
 
We as a specialty inherently make a biased judgement before we see patients or even allow patients through the door(based on data of course, pmhx,PMp, etc). Almost similar to “stop and frisk“ policy of Bloomberg. We use “pretest” probability to mitigate risky patients .
 
Last edited:
Probably get myself blocked for this (especially since I’m a lowly NP).... but I can’t help but notice how WILLING we are to recognize that COT isn’t indicated for chronic non-malignant pain so we are more than happy to filter these patients out... such a nuisance. BUT we are more than happy to do a vast array of equally/largely inefficacious interventions ($$$$$) on any and every patient ($$$) that somehow, by the grace of God/physician, is allowed to walk thru our pain mgmt doors ($$$).

I’ve worked in this specialty for many years... with multiple pain docs. Our success rates suck. The success stories make it worth it, but man. It kinda nauseates me to read lofty post after lofty post from docs unwilling to even give a second glance at a chronic pain patient who takes 5 oxy’s per day.... not even consider a consult.... even if the consult means advising tapering off. But, by golly, “Not-on-Opioids-JaneDoe’s” LRFA didn’t work the last time? Well, let’s repeat it for her... then if that doesn’t work, we’ll try the Sprint. Wait, that didn’t work? Ah, she’s got a bit of radiculitis now.... TFESI’s perhaps...of course they only lasted 2 weeks before but THIS time we’ll do two in a row.....two years later she’s got a VERTIFLEX. And since then we’ve sent her to collections because she hasn’t made sufficient payments on her $4,000 OOP ketamine infusions. I sense a bit of intellectual disingenuity on the part of some.

I tell my friends and family a few things for their health and well-being:
1) eat healthy, don’t smoke
2) avoid the dumb NP’s (they’re everywhere)
3) be leary of any treatment or medication newly on the market
4). Assume (until proven otherwise) any procedure being ordered by any subspecialist is for the purpose of purchasing their next yacht.
 
Last edited:
And yet what is the failure rate for spinal surgery done to treat pain? Also no one ever overdosed or was led to heroin use by one of my procedures.
 
mariajane said:
Probably get myself blocked for this (especially since I’m a lowly NP).... but I can’t help but notice how WILLING we are to recognize that COT isn’t indicated for chronic non-malignant pain so we are more than happy to filter these patients out... such a nuisance. BUT we are more than happy to do a vast array of equally/largely inefficacious interventions ($$$$$) on any and every patient ($$$) that somehow, by the grace of God, is allowed to walk thru our pain mgmt doors ($$$).

I’ve worked in this specialty for many years... with multiple pain docs. Our success rates suck. The success stories make it worth it, but man. It kinda nauseates me to read lofty post after lofty post from docs unwilling to even give a second glance at a chronic pain patient who takes 5 oxy’s per day.... not even consider a consult.... even if the consult means advising tapering off. But, by golly, “Not-on-Opioids-JaneDoe’s” LRFA didn’t work the last time? Well, let’s repeat it for her... then if that doesn’t work, we’ll try the Sprint. Wait, that didn’t work? Ah, she’s got a bit of radiculitis now.... TFESI’s perhaps...of course they only lasted 2 weeks before but THIS time we’ll do two in a row.....two years later she’s got a VERTIFLEX. And since then we’ve sent her to collections because she hasn’t made sufficient payments on her $4,000 OOP ketamine infusions.

I sense a bit of intellectual disingenuity on the part of some.
I tell my friends and family a few things for their health and well-being:
1) eat healthy, don’t smoke
2) avoid the dumb NP’s (they’re everywhere)
3) be leary of any treatment or medication newly on the market
4). Assume (until proven otherwise) any procedure being ordered by any subspecialist is for the purpose of purchasing their next yacht.
Click to expand...
Overall I agree with your point. Maybe it’s just like they say about lawyers where 95% of them give the rest a bad name.
To the point that started this thread though, no one ever threatened me with violence for refusing to do an epidural.
 
Laryngospasm said:
And yet what is the failure rate for spinal surgery done to treat pain? Also no one ever overdosed or was led to heroin use by one of my procedures.
Click to expand...

To your first question/point, depends on if spinal surgery is done indiscriminately vs on the right patient for the right condition in the right way...a fact which, perhaps, serves to affirm my diatribe.
 
Last edited:
You must log in or register to reply here.

Similar threads

Bhargava Kolli
Neurology to Pain Medicine
Replies
25
Views
2K
Bhargava Kolli
Bhargava Kolli
S
Pain medicine fellowship - Leftover spots
Replies
1
Views
1K
Fox800
Fox800
GoSpursGo
  • Locked
Pain Medicine political threads
Replies
0
Views
485
GoSpursGo
GoSpursGo
O
Seeking an advice on entering pain medicine from occupational medicine
Replies
10
Views
1K
occpain
O
A
Pain medicine reimbursements - ABMS/ABPM certification
Replies
1
Views
805
bedrock
bedrock
Top