give me "Pain medicine"

[Laryngospasm]

The same could be argued about procedures.. right patient right condition etc. what is the failure rate for PT? Chiro? Massage? Acupuncture? We are trying to help. Do I wish my procedures were 100% effective? Of course. We do what we can to try and help people and no I don’t feel bad for trying a 100-200$ Procedure with low risk to help someone especially to try and keep them from having a much more expensive and complicated surgery with higher risks, long recovery etc.

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[sloh]

How does performing largely ineffective procedures (regardless of their risk) make us any different than naturopaths?

 

[paindoc007]

How does performing largely ineffective procedures (regardless of their risk) make us any different than naturopaths?

We have a real degree after our names

 

[sloh]

We have a real degree after our names

The appeal to authority is a fallacy

 

[mariajane]

The same could be argued about procedures.. right patient right condition etc. what is the failure rate for PT? Chiro? Massage? Acupuncture? We are trying to help. Do I wish my procedures were 100% effective? Of course. We do what we can to try and help people and no I don’t feel bad for trying a 100-200$ Procedure with low risk to help someone especially to try and keep them from having a much more expensive and complicated surgery with higher risks, long recovery etc.

Indeed, and we know how we all feel about PT, chiro, massage, and acupuncture. Are you lumping pain mgmt into that group?

 

[myrandom2003]

How does performing largely ineffective procedures (regardless of their risk) make us any different than naturopaths?

Where is the science behind what naturopaths offer? We at least have some science and evidence behind RFA and SCS and vertebral aumentations.

Obviously not a cookie cutter process where its one treatment for all and patient selection matter.

But there is no evidence anywhere that continuing someone on 5 oxy's a day for non-cancer pain can improves disability for any duration of time or get anyone to keep working.

If there is evidence, please post it.
Also post some evidence that sprinkling herbs and drinking potions cures pain. (30% response is not an effective treatment, thats a placebo working)

 

[mariajane]

Where is the science behind what naturopaths offer? We at least have some science and evidence behind RFA and SCS and vertebral aumentations.

Obviously not a cookie cutter process where its one treatment for all and patient selection matter.

But there is no evidence anywhere that continuing someone on 5 oxy's a day for non-cancer pain can improves disability for any duration of time or get anyone to keep working.

If there is evidence, please post it.
Also post some evidence that sprinkling herbs and drinking potions cures pain. (30% response is not an effective treatment, thats a placebo working)

Yes, yes, the expected reply. Thus, we don’t even consider these patients for a consult. I get it.... completely.

 

[Ducttape]

for chronic noncancer pain, the reason our success rate sucks is because patients want a fix and they want someone else to do the fix, for a condition that is a maladaptive response.

I do agree that we have low success rates, but so does all of pain treatments.

unfortunately the current model for physicians is a fee for service one, and one that encourages procedures due to financial reimbursement. even medications - most of our "recommended" medications on EBM are not curing pain, and are even studied to just barely be clinically superior to placebo - in most cases only 2 point reduction in pain scale.

But there is no evidence anywhere that continuing someone on 5 oxy's a day for non-cancer pain can improves disability for any duration of time or get anyone to keep working.

worth re-iterating.

personally, i see all patients, except the ones who have exhibited aggression to staff. there is a purpose for my practice as a system HOPD department, but that is not the same purpose for physicians in private practice.

most pain docs do not want to deal with frustrated angry patients. they do not inspire us to see more people. and post negative reviews.

 

[TableMD]

I am a primary care sports doc, and 90-95% of my practice are referrals, many of which have an msk/neuro component and I often receive referrals from patients who have obtained evaluation from pain doctors. I likewise am almost entirely opiod free, however I do have a few who receive those medications. One lady used to be on a higher dose of oxy and I got her on a fairly low dose of tramadol after a series of peripheral nerve blocks, topical compounded txs and some other interventions. Her PCP would not refill her tramadol (since she ironically wrote for the higher dose oxy but has since said "not it" with opioids for her and some others she sent me) so I took it over. I use the tramadol as tool to get her to do everything else I want sorted from her. The few others are similar.

Reading this I see both sides, but I have to say that filtering out a patient without a thoughtful evaluation is a major buzzkill. Since my initial training is in family medicine, I gotta say that if you refused to see a patient of mine outright, I would likely never use you again if there were equally good options. A pcp, who sees such a patient on follow up, often has to address more immediate, potentially lethal problems (smoking, hypertension, cancer screening updates) that even if they have the comfort in knowing what needs to happen with the patient, they need help in having the tough talks about pain which as you all know is a time suck.

When I was in my sports fellowship, duding the once a week, half day rotation at the primary care clinic, I had a patient who I had to tell that she had hepatitis C and an STI and so I didn't have time to address her rotator cuff issue, so I referred her to myself to see me about that when I was at the sports clinic (we had a "fellows clinic block" that I could get her in).

I am assuming as part of pain fellowship you do a somewhat deeper dive into the pharmacology and workup of pain (pathophys/ddx/workup/options) and so to take those abilities off the table since the patient has some dings in their paperwork is unfortunate. A thoughtful note can help the PCP do their job, even if the patient isn't happy about it. What is described in this thread in my opinion is like a cardiologist not wanting to talk to a hypertensive patient due to the likelihood that the patient will need medical management over a cath.

Just to be clear, I don't any doctor should write for a med they are not comfortable with.

 

[callmeanesthesia]

I don’t write for any opioids (other than the occasional acute pain issue) but I certainly don’t reject referrals for being on opioids. However, when the referral states “patient angrily stormed out of my office when he was told I would not be refilling his Norco due to cocaine in UDS. Will refer to pain management.” I see that as a danger to myself and my staff to accept the referral. I’m not an addictionologist and furthermore that is not someone who is ready to accept they have a problem.
If on the other hand it seems that a patient is in opioids because they didn’t know there were other options, I’ll instruct the new patient coordinators to let them know up front I don’t prescribe opioids, but likely do have other options to offer.

 

[myrandom2003]

Since my initial training is in family medicine, I gotta say that if you refused to see a patient of mine outright, I would likely never use you again if there were equally good options. A pcp, who sees such a patient on follow up, often has to address more immediate, potentially lethal problems (smoking, hypertension, cancer screening updates) that even if they have the comfort in knowing what needs to happen with the patient, they need help in having the tough talks about pain which as you all know is a time suck.

For arguments sake, this street goes both ways. If I have a PCP who is running patient up on opioids and then referring them out for someone else to deal with, I wouldn't accept any further referrals from that PCP. I have already done this with one PCP in my former area. Taking over mismanagement and putting my name on a chart is not my idea of fun. Send me a patient to start the workup and treatment, i'll take those all day.

We don't screen in my current clinic, so everyone gets through, and sometimes it gets confrontational because I won't take over the fentanyl and oxy combo and the patient was told by the PCP that I would take over.

If I had my way, I would screen, and if the patient has tried everything, then its a waste of my time and patients time to re-invent the wheel.
If the patient hasn't tried everything and there was something I could offer, I would see the patient as long as they know I won't take over the meds . I'm sure most of the people on here are the same way.

Also, I haven't heard of any cardiologists being under DEA scrutiny for overprescribing statins. Cardiologists are also not prescribing medications without an objective measurable endpoint. BP, cholesterol all have numbers to justify treatments. I know many cardiologists that have cath'd on a very very soft call (read that as not indicated). fee for service means the more you do, the more you make. That cardiologist you referred to, sends that patient to his NP.


The problem with pain is, that it is an experience, and does not necessarily require tissue damage to be present. This is what makes it so difficult to treat. In a fee for service world with declining reimbursement, also makes it not worth the additional time to tease out the psych.
It sucks, but thats just the way in this country. And mental health has such a stigma, its tough to get pain patient to buy into seeking care via that route.
To paraphrase a dannimiller lecture.

 

[Keona]

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?

I don’t usually refer to them. The patients I see are typically older and frailer and don’t qualify for nsaids Due to age or renal function and have frequently already had injections that they didn’t respond to. If I send a patient like that to someone who only does injections then everyone is going to be annoyed with the situation. If a patient has no interest in medication management then I’ll refer to the anesthesiologist we have locally who will do many injections.
If I’m at the point from a medication standpoint where I feel like I need help I don’t want to see them to someone who does injections only since they often need a multimodal approach.

 

[myrandom2003]

If I’m at the point from a medication standpoint where I feel like I need help I don’t want to see them to someone who does injections only since they often need a multimodal approach.

So does that mean, if you need help from a medication management regimen and the pain doc makes recommendations and sends back to you, you are ok with that?

Or do you mean help as is in, you don’t feel comfortable escalating medication any longer and want someone else to take over?
Is these instances, many if not all pain docs prefer to be the ones to start medications.


Opioids, like entitlement programs, are hard to roll back/discontinue once started. Which is why most legit pain docs are judicious with their RX pads and won’t start or want to take over the medications they don’t want to continue.

Those elderly patients you mentioned also should not be on 4 hydrocodone/apap a day with their decreased ability to clear medication as well as the effects opioids have on their mentation, balance, constipation, immune response blunting etc

 

[Keona]

So does that mean, if you need help from a medication management regimen and the pain doc makes recommendations and sends back to you, you are ok with that?

Or do you mean help as is in, you don’t feel comfortable escalating medication any longer and want someone else to take over?
Is these instances, many if not all pain docs prefer to be the ones to start medications.


Opioids, like entitlement programs, are hard to roll back/discontinue once started. Which is why most legit pain docs are judicious with their RX pads and won’t start or want to take over the medications they don’t want to continue.

Those elderly patients you mentioned also should not be on 4 hydrocodone/apap a day with their decreased ability to clear medication as well as the effects opioids have on their mentation, balance, constipation, immune response blunting etc

I don’t start anyone on pain medications. If they need to start on them I refer to pain management to start. I’ve only been in practice two years and several when I started were on low doses of opiates. Some are also on higher doses. (Took over from a retired physician) I’ve told all of them if they are going to require escalation I will refer to pain management to come up with a further plan. I continue what they’ve currently been on that is working if causing no side effects and no red flags. I’ve only had to refer out a few of them that were already on medications. One of the pain management doctors did more a consultation where they and patient came up with a plan for a more appropriate opiate plan which I continued. I absolutely agree they should not be on those high doses of pain meds. Completely agree that once they are on them and habituated to them it is almost impossible to stop the regimens. That’s why I far prefer sending to a pain management doctor to start with. I also never promise a patient that another physician will prescribe medications. (One example I’ve got is a patient who takes like 30 tramadol per 2 years). Recently had a patient who started to develop renal failure on nsaids. In excruciating pain after nsaid discontinued. Referred to pain management and they started on low doses of opiates and injections and seems To be able to enjoy life again.