How to avoid Fibromyalgia only Referrals?

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SpineandWine

SpineandWine

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Hi, just started a practice at a hospital and much of what I'm seeing is Fibromyalgia + Opiates that other clinics do not want.
My goal is to ramp up (as I'm setting 4-5 patients a day) with plans to build a more interventional practice. What advice do you have to try and achieve this?
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anujacket said:
Hi, just started a practice at a hospital and much of what I'm seeing is Fibromyalgia + Opiates that other clinics do not want.
My goal is to ramp up (as I'm setting 4-5 patients a day) with plans to build a more interventional practice. What advice do you have to try and achieve this?
Click to expand...

 
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either you or a staff member needs to be reviewing your incoming consults. anything that smells of fibromyalgia should be told that you do not treat this condition if you do not wish to. ideally you would train someone to do a proper intake screen to make sure only appropriate patients get scheduled with you. anything questionable should come across your desk for review before being given an appointment.

you may need to reach out directly to the referring physicians and let them know you don't have any options for these patients and they are better served elsewhere.
 
Give yourself a fake 4 star review that says you’re a nice doctor but you didn’t continue the pain meds they were hoping for their fibromyalgia and they wished they had known before the visit to save their copay.

That should do the trick 😉
 
Agast said:
Give yourself a fake 4 star review that says you’re a nice doctor but you didn’t continue the pain meds they were hoping for their fibromyalgia and they wished they had known before the visit to save their copay.

That should do the trick 😉
Click to expand...
How have I never thought of doing this before? Genius.
 
MM had a post a few years back where he stated to referring docs and patients that he just wasn't good at managing fibromyalgia, just didn't have good outcomes with managing it and wasn't any good at it - and that worked for him.
 
I hand out a patient fact sheet from the American College of Rheumatology (the ones who invented this condition) about Fibromyalgia.

It states "Opioids, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) and sleep medicines like zolpidem (Ambien) are not recommended for use in treating fibromyalgia symptoms".

It also states "Exercise is the most effective treatment, including low-impact aerobic activity and body-based therapies like tai chi or yoga"

Wean and stop the opiates, give a referral for pool PT, and document in your note your evidence based treatment for the referring provider. You can also set up meeting with these referring providers to help them understand correct treatment and increase good referrals.
 

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Ferrismonk said:
I hand out a patient fact sheet from the American College of Rheumatology (the ones who invented this condition) about Fibromyalgia.

It states "Opioids, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) and sleep medicines like zolpidem (Ambien) are not recommended for use in treating fibromyalgia symptoms".

It also states "Exercise is the most effective treatment, including low-impact aerobic activity and body-based therapies like tai chi or yoga"

Wean and stop the opiates, give a referral for pool PT, and document in your note your evidence based treatment for the referring provider. You can also set up meeting with these referring providers to help them understand correct treatment and increase good referrals.
Click to expand...
wow. gift dropped from the heavens. printing 100 copies as we speak.
 
anujacket said:
Hi, just started a practice at a hospital and much of what I'm seeing is Fibromyalgia + Opiates that other clinics do not want.
My goal is to ramp up (as I'm setting 4-5 patients a day) with plans to build a more interventional practice. What advice do you have to try and achieve this?
Click to expand...
Why don’t you want them? They are what I like to call - a target rich environment for procedures. Money money money!
 
Ferrismonk said:
I hand out a patient fact sheet from the American College of Rheumatology (the ones who invented this condition) about Fibromyalgia.

It states "Opioids, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) and sleep medicines like zolpidem (Ambien) are not recommended for use in treating fibromyalgia symptoms".

It also states "Exercise is the most effective treatment, including low-impact aerobic activity and body-based therapies like tai chi or yoga"

Wean and stop the opiates, give a referral for pool PT, and document in your note your evidence based treatment for the referring provider. You can also set up meeting with these referring providers to help them understand correct treatment and increase good referrals.
Click to expand...
The ones who invented and refuse to treat
 
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I had a lady referred to me for fibromyalgia who turned out to have bilateral rotator cuff tears, an L5-S1 disc problem and GT bursitis. Some docs forget the diagnosis of exclusion part…
 
I like the idea of intake change and 4 star reviews (though may be meant as a joke, it could work). I’ll see everyone once to build relationships and then My goal is to then just say following plan (hope after a while those referrals will dim down):

Diffuse body pain consistent with fibromyalgia:
I discussed with the patient today that by the American College of Rheumatology 1991 and updated 2011 criteria, she does meet the diagnostic criteria for fibromyalgia. We discussed a comprehensive approach to the management of fibromyalgia. The patient received patient information on the diagnosis and self-management strategies of fibromyalgia. We also discussed the importance of good sleep hygiene and that poor sleep can exacerbate fibromyalgia. The patient was given patient education information including resources and strategies to improve sleep.

PCP could consider referral to medical psychology and PT as part of comprehensive evaluation.
To rule out a coexisting medical disorder as the underlying cause of the numbness and pain, several labs were ordered today, summarized below.

Opioid therapy for this diagnosis is relatively contrindicated as opioid therapy has been shown to worsen this condition over time. We do not prescribe patients with fibromyalgia opioids (with the exception of Tramadol) and there is no specific indication for interventional therapy. I have made several recommendations listed below.

There are 3 FDA approved medications for the treatment of fibromyalgia; Lyrica, Cymbalta, and Savella. Several other medications may also be used "off label" including Gabapentin, TCA's, muscle relaxants for treatment.
There is some evidence supporting the use Naltrexone 4.5mg Daily (must be obtained from a compounding pharmacy) is helpful in fibromyalgia. (Younger et al. Pain Medicine. 2009. Vol 10. No 4).
Moreover there is a single study supporting the use of Memantine 10-20mg daily for the treatment of fibromyalgia. (Oliver-Blazquez et al. Pain. 2014. Vol 155. 2517-2525).
Several other complimentary techniques have also been utilized in order to help control pain, but are not supported with evidence from the medical literature. These techniques include Acupuncture, Massage Therapy, Yoga, hypnosis, and/or relaxation training.
 
Fibromyalgia is just a symptom of central sensitization, not a diagnosis IMO. They do well at the Mayo Pain Rehab Clinic, 87% success rate. Send referral there
 
Good stuff….. but I still don’t want to see it.
anujacket said:
I like the idea of intake change and 4 star reviews (though may be meant as a joke, it could work). I’ll see everyone once to build relationships and then My goal is to then just say following plan (hope after a while those referrals will dim down):

Diffuse body pain consistent with fibromyalgia:
I discussed with the patient today that by the American College of Rheumatology 1991 and updated 2011 criteria, she does meet the diagnostic criteria for fibromyalgia. We discussed a comprehensive approach to the management of fibromyalgia. The patient received patient information on the diagnosis and self-management strategies of fibromyalgia. We also discussed the importance of good sleep hygiene and that poor sleep can exacerbate fibromyalgia. The patient was given patient education information including resources and strategies to improve sleep.

PCP could consider referral to medical psychology and PT as part of comprehensive evaluation.
To rule out a coexisting medical disorder as the underlying cause of the numbness and pain, several labs were ordered today, summarized below.

Opioid therapy for this diagnosis is relatively contrindicated as opioid therapy has been shown to worsen this condition over time. We do not prescribe patients with fibromyalgia opioids (with the exception of Tramadol) and there is no specific indication for interventional therapy. I have made several recommendations listed below.

There are 3 FDA approved medications for the treatment of fibromyalgia; Lyrica, Cymbalta, and Savella. Several other medications may also be used "off label" including Gabapentin, TCA's, muscle relaxants for treatment.
There is some evidence supporting the use Naltrexone 4.5mg Daily (must be obtained from a compounding pharmacy) is helpful in fibromyalgia. (Younger et al. Pain Medicine. 2009. Vol 10. No 4).
Moreover there is a single study supporting the use of Memantine 10-20mg daily for the treatment of fibromyalgia. (Oliver-Blazquez et al. Pain. 2014. Vol 155. 2517-2525).
Several other complimentary techniques have also been utilized in order to help control pain, but are not supported with evidence from the medical literature. These techniques include Acupuncture, Massage Therapy, Yoga, hypnosis, and/or relaxation training.
Click to expand...
 
Brachialis021 said:
Fibromyalgia is just a symptom of central sensitization, not a diagnosis IMO. They do well at the Mayo Pain Rehab Clinic, 87% success rate. Send referral there
Click to expand...

What's the 5-year remission rate? I know, because I did my research project there as a resident. 87% are not cured at 5-years.
 
drusso said:
What's the 5-year remission rate? I know, because I did my research project there as a resident. 87% are not cured at 5-years.
Click to expand...

Therein lies your problem. He said success, you say cure. In fibromyalgia are those two words synonymous to you?
 
similar position as original poster, but what if you were taking over a previous pain doc's practice instead - previous pain doc had a lot of patients on opioids (some just for fibro) and obviously the PCPs are expecting you to take over the script. also probably don't wanna piss off the PCPs since they give you referrals. how do you even wean these patients since "nothing works for my pain" (meds and procedures)?
 
Serial pill counts, tell them you will prescribe but only butrans, or tramadol, or max 10 mme of their current opioid, talk about opioid induced hypergesia, state that they will need to show clear dedication to an exercise program, or attend pt, stop smoking, lose weight, see a psychologist regularly…when they realize getting a second opinion from a pill guy will be easier than continuing to see you, they will just leave hopefully. If this is a practice you want to be in for a while I would do yourself a favor and just tell all of them immediately you do not prescribe opioids for fibromyalgia but will continue (with weaned dose if tou want) for a max of 3 months while they find a second opinion. That way you’ll be done with it by 2022. Also, Pcps know by now that opioids for fibro is not a thing.
 
I would outline evidence bases treatment guidelines and your plan to a wean then give them 1-2 months to find alternative treatment if they don't like your plan. This also gives you some time to build rapport with the PCPs before the patients start complaining loudly.

I would caution against the "No opioids for fibro" talk when you're dealing with existing patients. I gaurantee they will suddenly remember that their meds aren't for their fibro, it's really for their mild knee OA or "that disc" that is mildly degenerated.
 
Lots of advice. Just keep it simple.
Tell the PCP you will see all of them and be the bad guy.
PCP stops Rx when they see you and you will Rx if appropriate, but they should not.
You determine what is appropriate care.
Patient blames you. You got PCP's back.
Patient off opiates if not appropriate and PCP thanks you.
Problem solved.
 
lobelsteve said:
Lots of advice. Just keep it simple.
Tell the PCP you will see all of them and be the bad guy.
PCP stops Rx when they see you and you will Rx if appropriate, but they should not.
You determine what is appropriate care.
Patient blames you. You got PCP's back.
Patient off opiates if not appropriate and PCP thanks you.
Problem solved.
Click to expand...
I wish the pcps were like that in my area. You get notes that say “patient did not like the way they were treated by PM doc. Will refer to new PM doc.”

No mention that the difference in opinion was somebody got dismissed. They just pass the buck to the next guy because they are spineless.
 
This is one of the perks of working in a large ortho practice. It’s not perfect, but there are zero issues simply telling patients I/we don’t prescribe chronic opioids, don’t treat fibromyalgia, etc in this practice. I may choose to with a select few patients, but zero obligation. You may see it as a cop out, but it makes my life so much easier. Same response to “pcp dumped opioid/benzo patient on me” thread. Not my circus, not my monkey….
 
geauxg8rs said:
I wish the pcps were like that in my area. You get notes that say “patient did not like the way they were treated by PM doc. Will refer to new PM doc.”

No mention that the difference in opinion was somebody got dismissed. They just pass the buck to the next guy because they are spineless.
Click to expand...
Do bear in mind that there's a 100% chance the patients lie to us about why they want a new doctor.

It's always some combination of they are mean, they don't answer the phones, their staff is rude, you get the idea.

That aside, none of us really like refusing to place referrals for patients when they ask for it unless they want to go to a certain kind of position that doesn't treat the problem they have. If it's something that we can handle or think is inappropriate, I think most of us will make an effort to say that either we can take care of it or that we don't think the specialist will be able to help them. But if they are insistent, I think I can count on one hand the number of times I've flat refused a referral request.
 
geauxg8rs said:
I wish the pcps were like that in my area. You get notes that say “patient did not like the way they were treated by PM doc. Will refer to new PM doc.”

No mention that the difference in opinion was somebody got dismissed. They just pass the buck to the next guy because they are spineless.
Click to expand...
Set expectations with pcp before they start referring. They now send more acute vcf than fms.
 
Taus said:
This is one of the perks of working in a large ortho practice. It’s not perfect, but there are zero issues simply telling patients I/we don’t prescribe chronic opioids, don’t treat fibromyalgia, etc in this practice. I may choose to with a select few patients, but zero obligation. You may see it as a cop out, but it makes my life so much easier. Same response to “pcp dumped opioid/benzo patient on me” thread. Not my circus, not my monkey….
Click to expand...
from personal experience, these patients get dumped on other pain docs.

the ortho docs in your practice are probably referring to outside pain doctors. these patients dont go away from the system, they go away from the ortho clinic, and that clinic takes no responsibility any longer, even if they were the ones to start the cycle by starting opioids after some procedure. they get dumped so you guys can continue to rake in the money.

a lot of these patients get seen in hospital clinics.
 
Ducttape said:
from personal experience, these patients get dumped on other pain docs.

the ortho docs in your practice are probably referring to outside pain doctors. these patients dont go away from the system, they go away from the ortho clinic, and that clinic takes no responsibility any longer, even if they were the ones to start the cycle by starting opioids after some procedure. they get dumped so you guys can continue to rake in the money.

a lot of these patients get seen in hospital clinics.
Click to expand...
Bingo
 
Hopefully, we will soon recognize FM as an autoimmune condition that should be dealt with in rheum clinics:

Andreas Goebel, Emerson Krock, Clive Gentry, Mathilde R. Israel, Alexandra Jurczak, Carlos Morado Urbina, Katalin Sandor, Nisha Vastani, Margot Maurer, Ulku Cuhadar, Serena Sensi, Yuki Nomura, Joana Menezes, Azar Baharpoor, Louisa Brieskorn, Angelica Sandström, Jeanette Tour, Diana Kadetoff, Lisbet Haglund, Eva Kosek, Stuart Bevan, Camilla I. Svensson, David A. Andersson. Passive transfer of fibromyalgia symptoms from patients to mice. Journal of Clinical Investigation, 2021; 131 (13) DOI: 10.1172/JCI144201
 
chibadriver said:
Hopefully, we will soon recognize FM as an autoimmune condition that should be dealt with in rheum clinics:

Andreas Goebel, Emerson Krock, Clive Gentry, Mathilde R. Israel, Alexandra Jurczak, Carlos Morado Urbina, Katalin Sandor, Nisha Vastani, Margot Maurer, Ulku Cuhadar, Serena Sensi, Yuki Nomura, Joana Menezes, Azar Baharpoor, Louisa Brieskorn, Angelica Sandström, Jeanette Tour, Diana Kadetoff, Lisbet Haglund, Eva Kosek, Stuart Bevan, Camilla I. Svensson, David A. Andersson. Passive transfer of fibromyalgia symptoms from patients to mice. Journal of Clinical Investigation, 2021; 131 (13) DOI: 10.1172/JCI144201
Click to expand...

Amazing that they got the mice to take the WPI and SSS surveys.

 
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