needles vs narcotics -- revisited

[ParaVert]

A tangential debate in another thread (consult vs referral) seems to have awakened the dragon...

Let's have an honest, open discussion about our thoughts and biases regarding the prescribing of opioids for pain conditions. I bring this up, because there still seems to be opposing teams within the pain physician community, each side completely convinced by their own BS. Most community docs agree that a balanced technique utilizing medical and interventional treatments seems to work best. I don't want this to be a debate between the extremes, more like a confessional for those who find themselves conflicted in their professional practice. Those docs out there who have it all figured out---keep it to yourself.

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[ParaVert]

So here are my thoughts, flame me at will...

Chronic pain is an untreatable condition characterized by a patient's biopsychosocial milieu, not disease pathology. There exists no effective, proven treatment for chronic pain. The application of existing therapies, both pharmacologic and interventional, often results in dissatisfaction both on the part of the patient and practitioner. I as a pain physician pray daily to avoid chronic pain patients, simply because I have nothing to offer them--at least nothing I believe in.

All that being said, I love to treat chronic conditions characterized by occasional acute, painful exacerbations. Lumbar radiculitis, facet arthropathy, vertebral compression fractures, localized cancer pain, peripheral neuropathy (that which responds to AEDs and SCS, of course). No matter what I choose (needles, narcotics, or a pious multimodal smattering), most people feel better faster than if I did nothing. Either way, the patient is grateful and I feel like I did a good job.

To tie into the opioid debate, I believe that most pain guys begrudgingly prescribe chronic opioids either to keep their referring docs happy or to compete in their market. I applaud Tenesma for voicing (albeit loudly) his frustration with chronic opioid therapy and his efforts to minimize his actual prescribing of them. In fact, I hope to do the same in my private practice in a few months. This isn't to say that opioids aren't an important part of the arsenal, but I know that patients on chronic opioids have chronic pain that isn't getting better anytime soon. Patients who don’t get better are dissatisfied. That makes me dissatisfied.

Sure, you may argue that this rational does nothing for the masses with chronic, intractable pain. Perhaps, but I'm not campaining to end hunger or for world peace either. I just want a practice that makes me happy and keeps me fed. A procedure-based practice, with minimal opioid management, self-selects patients with more acutely painful conditions. These people are more likely to get better.

As physicians, who doesn't want that?

 

[mille125]

So here are my thoughts, flame me at will...

Chronic pain is an untreatable condition characterized by a patient's biopsychosocial milieu, not disease pathology. There exists no effective, proven treatment for chronic pain. The application of existing therapies, both pharmacologic and interventional, often results in dissatisfaction both on the part of the patient and practitioner. I as a pain physician pray daily to avoid chronic pain patients, simply because I have nothing to offer them--at least nothing I believe in.

All that being said, I love to treat chronic conditions characterized by occasional acute, painful exacerbations. Lumbar radiculitis, facet arthropathy, vertebral compression fractures, localized cancer pain, peripheral neuropathy (that which responds to AEDs and SCS, of course). No matter what I choose (needles, narcotics, or a pious multimodal smattering), most people feel better faster than if I did nothing. Either way, the patient is grateful and I feel like I did a good job.

To tie into the opioid debate, I believe that most pain guys begrudgingly prescribe chronic opioids either to keep their referring docs happy or to compete in their market. I applaud Tenesma for voicing (albeit loudly) his frustration with chronic opioid therapy and his efforts to minimize his actual prescribing of them. In fact, I hope to do the same in my private practice in a few months. This isn't to say that opioids aren't an important part of the arsenal, but I know that patients on chronic opioids have chronic pain that isn't getting better anytime soon. Patients who don’t get better are dissatisfied. That makes me dissatisfied.

Sure, you may argue that this rational does nothing for the masses with chronic, intractable pain. Perhaps, but I'm not campaining to end hunger or for world peace either. I just want a practice that makes me happy and keeps me fed. A procedure-based practice, with minimal opioid management, self-selects patients with more acutely painful conditions. These people are more likely to get better.

As physicians, who doesn't want that?

I would like everyone to read my post in the consult vs referral forum so that I do not need to rewrite it. My main criticism of tenesma is not that he refuses to write opioids. I criticize him because he says that the real reason is because there are no studies backing up this approach. Even though this is true, you can quite easily adopt the same strategy about most interventional techniques. As Gorback illustrated, we, as interventional pain management physicians, should not play the "studies" game.


So lets get to the heart of the matter. The real reason that Tenesma has this attitude is that he is "uncomfortable" with the societal risks that may be attributed to these drugs (he did not want to say this so I have said it for him). I do not believe that he simply wants to make more money even though there are some doctors are out there. I think that it is both sad and unfortunate if a physician who devotes most of his professional career to pain relief is fearful of the use of opioids in their patients. Yes, there are patients who abuse or divert the drugs. Yes, there is opioid induced hyperalgesia. Yes, there are other side effects (constipation, sexual dysfunction, etc.). However, there is a subset of the population who has functional improvement not the mention substantial pain relief from these medications. Paravert, I would say to you that you are in medicine to help your patients first and foremost. You must do this despite your own financial gain, etc. You are doing your patients a disservice if you have the power to help them become a productive member of society and choose not to help them.

In no way am I telling you that you should continue to refill opioids if they are not benefitting the patient. I probably taper more patients off of opioids than I start on them. I try to assess functional improvement every 6-9 months to guide me. I have a zero tolerance policy for aberrant behavior. My PCP's appreciate it because they feel that I am a resource to them. Most importantly the patients appreciate it. I have received heart felt letters from patients who I have started on opioids as well as those that I have tapered.


Lastly, paravert, I would like to respond to your comment about not wanting to treat chronic pain patients. Every specialty has there share of difficult patients. Cardiologists do not like to treat angina patients who are not stent candidates or CABG candidates secondary to poor targets. Vascular surgeons are afflicted by some severely vasculopathic patients. Pediatricians have trouble with patients in difficult family and social situations. The list goes on. You would never hear of these doctors giving up on these patients. You freely chose this specialty and owe it to the patients to attempt to try to treat them. You will not be successful with all but you need to try.

 

[drusso]

Here are my thoughts...

Chronic pain is an incurable, but TREATABLE, condition characterized by sustained and maladaptive peripheral and central neurologic/nociceptive processing mechanisms, psychiatric sequelae, maladaptive behavior and psychosocial strain. Coordinated, multimodal, behaviorally-based treatments have substantial scientific evidence supporting their efficacy, but are unavailable, under-utilized, or unaffordable to the overwhelming majority of patients who need them most.

Long-term opioid therapy is of limited benefit. A small minority of patients with chronic pain are indeed able to demonstrate sustained long-term functional improvement on ACTIVELY medically-supervised opioid treatment that is used in conjunction, and conditionally, with other treatments (physical therapy, cognitive therapy, etc).

However, there are no reliable means to select likely "responders" to this treatment, and pain physicians accept substantial liability and risk exposure by agreeing to manage long-term opioid therapy. Therefore, more than perhaps any other dimension of the patient-doctor relationship, a decision to pursue long-term opioid therapy is based upon mutual trust. One little screw up...you're done. Most patients make it pretty easy for me to fire them or demonstrate that the opioids aren't "working" based upon their own dissatisfaction and functional stagnation.

The most valuable things I have to offer patients with chronic pain is an expert opinion about the nature of their condition, a procedural intervention when indicated, and an opportunity to persuade them away from harmful or ineffective treatments and "the acute pain model" for a chronic pain problem.

 

[mille125]

To the "I never prescribe opioids for chronic pain crowd" I have the following questions:



1) Do you perform intrathecal pumps? If so, how do you justify this.
2) How would you treat the following patient

Patient with coronary stents placed 2 months ago. Cardiologist says that they need to stay on plavix for a full year. Patient has L4/L5 disk extrusion and associated symptoms. PT and conservative meds (NSAIDS, anticonvulsants) have failed.


Patient takes methadone 5 mg tid with 60% decrease in pain score and 50% improvement in function. Patient has a central pain syndrome and does not have aberrant behavior.

 

[mille125]

Here are my thoughts...

Chronic pain is an incurable, but TREATABLE, condition characterized by sustained and maladaptive peripheral and central neurologic/nociceptive processing mechanisms, psychiatric sequelae, maladaptive behavior and psychosocial strain. Coordinated, multimodal, behaviorally-based treatments have substantial scientific evidence supporting their efficacy, but are unavailable, under-utilized, or unaffordable to the overwhelming majority of patients who need them most.

Long-term opioid therapy is of limited benefit. A small minority of patients with chronic pain are indeed able to demonstrate sustained long-term functional improvement on ACTIVELY medically-supervised opioid treatment that is used in conjunction, and conditionally, with other treatments (physical therapy, cognitive therapy, etc).

However, there are no reliable means to select likely "responders" to this treatment, and pain physicians accept substantial liability and risk exposure by agreeing to manage long-term opioid therapy. Therefore, more than perhaps any other diminesion of the patient-doctor relationship, a decision to pursue long-term opioid therapy is based upon mutual trust. One little screw up...you're done. Most patients make it pretty easy for me to fire them or demonstrate that the opioids aren't "working" based upon their own dissatisfaction and functional stagnation.

The most valuable things I have to offer patients with chronic pain is an expert opinion about the nature of their condition, a procedural intervention when indicated, and an opportunity to pursudae them away from harmful or ineffective treatments and "the acute pain model" for a chronic pain problem.

very good...i applaud you and would be honored to work with you.

 

[lobelsteve]

To the "I never prescribe opioids for chronic pain crowd" I have the following questions:



1) Do you perform intrathecal pumps? If so, how do you justify this.
2) How would you treat the following patient

Patient with coronary stents placed 2 months ago. Cardiologist says that they need to stay on plavix for a full year. Patient has L4/L5 disk extrusion and associated symptoms. PT and conservative meds (NSAIDS, anticonvulsants) have failed.


Patient takes methadone 5 mg tid with 60% decrease in pain score and 50% improvement in function. Patient has a central pain syndrome and does not have aberrant behavior.

I strongly disagree with the use of Methadone in CAD patients. I would also avoid the use of Darvocet and Demerol. But if you substitute any other opioid- or if you tried all other opioids without success and documented this and that the Methadone was not the top choice with clearly defined risks/benefits discussed with the patient- then I agree 100%.

 

[lobelsteve]

I would like everyone to read my post in the consult vs referral forum so that I do not need to rewrite it. My main criticism of tenesma is not that he refuses to write opioids. I criticize him because he says that the real reason is because there are no studies backing up this approach. Even though this is true, you can quite easily adopt the same strategy about most interventional techniques. As Gorback illustrated, we, as interventional pain management physicians, should not play the "studies" game.


So lets get to the heart of the matter. The real reason that Tenesma has this attitude is that he is "uncomfortable" with the societal risks that may be attributed to these drugs (he did not want to say this so I have said it for him). I do not believe that he simply wants to make more money even though there are some doctors are out there. I think that it is both sad and unfortunate if a physician who devotes most of his professional career to pain relief is fearful of the use of opioids in their patients. Yes, there are patients who abuse or divert the drugs. Yes, there is opioid induced hyperalgesia. Yes, there are other side effects (constipation, sexual dysfunction, etc.). However, there is a subset of the population who has functional improvement not the mention substantial pain relief from these medications. Paravert, I would say to you that you are in medicine to help your patients first and foremost. You must do this despite your own financial gain, etc. You are doing your patients a disservice if you have the power to help them become a productive member of society and choose not to help them.

In no way am I telling you that you should continue to refill opioids if they are not benefitting the patient. I probably taper more patients off of opioids than I start on them. I try to assess functional improvement every 6-9 months to guide me. I have a zero tolerance policy for aberrant behavior. My PCP's appreciate it because they feel that I am a resource to them. Most importantly the patients appreciate it. I have received heart felt letters from patients who I have started on opioids as well as those that I have tapered.


Lastly, paravert, I would like to respond to your comment about not wanting to treat chronic pain patients. Every specialty has there share of difficult patients. Cardiologists do not like to treat angina patients who are not stent candidates or CABG candidates secondary to poor targets. Vascular surgeons are afflicted by some severely vasculopathic patients. Pediatricians have trouble with patients in difficult family and social situations. The list goes on. You would never hear of these doctors giving up on these patients. You freely chose this specialty and owe it to the patients to attempt to try to treat them. You will not be successful with all but you need to try.

Ditto that 100%.

Did some of you not get the lectures on Substance abuse, Opioid Rx writing, Opioid risk factors and patient selection. Opioids work. They do have a huge downside as well. Know your drugs, know your patients, know your patient's drugs. Check out algos's website and his lecture on Opioids. If a practice is needles only, it exists to make money and not to treat patients. If a practice is medication only, it exists to deal drugs and make patients happy. The multidisciplinary approach has good data to support it and it makes sense. If you do not offer meds, needles, PT, electric therapy (TENS, RS4i, IF3, etc), clinical psych- then why are you shortchanging your patients? I think a good pain doc knows what and when to use to best treat a patient- but to shun any one of these modalities as a general rule is shortsighted and unfair to your patients.

 

[PainDr]

I also wholeheartedly agree with Mille125.

Chronic pain is an untreatable condition characterized by a patient's biopsychosocial milieu, not disease pathology. There exists no effective, proven treatment for chronic pain. I as a pain physician pray daily to avoid chronic pain patients, simply because I have nothing to offer them--at least nothing I believe in.

Wow...you must be praying alot. I'm not sure how to respond to this, it's such a broad generalization. I can only assume you are burned out by fellowship and hope you will eventually change your opinion. I know your faculty and know this is not their philosophy.

All that being said, I love to treat chronic conditions characterized by occasional acute, painful exacerbations. Lumbar radiculitis, facet arthropathy, vertebral compression fractures, localized cancer pain, peripheral neuropathy (that which responds to AEDs and SCS, of course).

Patients with these conditions almost always have some baseline pain. What about that? Do you just ignore it? I agree that using interventions to successfully treat acute exacerbations is very rewarding both for the patient and physician, but to use them as your sole treatment modality is short sighted and callous.

Sure, you may argue that this rational does nothing for the masses with chronic, intractable pain. Perhaps, but I'm not campaining to end hunger or for world peace either. I just want a practice that makes me happy and keeps me fed. A procedure-based practice, with minimal opioid management, self-selects patients with more acutely painful conditions. These people are more likely to get better.

As physicians, who doesn't want that?

If you want to cherry pick your patients, that is your business, just don't pretend it's all for the greater good.

 

[ParaVert]

Wow, I'm really enjoying the progress thus far. We spend way too much time discussing the subtleties of certain procedures, it is nice to have a discussion about practice philosophy. That, by far, is the greatest benefit I have gotten from this forum.

To redirect, I also believe that a multifaceted approach to pain management is better than either extreme (all procedures or all prescriptions). The example that was given of a patient with disc herniation on chronic anticoagulation is a good example of a patient with an acute, well defined pain problem. This is probably agood patient for opioid therapy. I would not call that scenerio a "chronic pain" problem. Would anyone?

All I'm saying is that we still try to use acute pain techniques to treat some patients with chronic pain in which NOTHING helps. Hasn't everybody seen some of these patients? You do some blocks, you give some meds, their functionality is still poor and their pain scales are still high. Almost without fail, these people still want narcotics even though there is no objective evidence of improvement in their function. Even the pro-opioid posts sound like you'd stop opioids unless the patient proves they are actually getting objective benefit. Sounds good to me too. The problem is when those patients hassle your staff or your referring docs incessantly because you cut them off. It just seems easier to try to tailor your practice to minimize the number of referrals for chronic, intractable whole body pain unresponsive to everything ten other physicians have tried BEFORE they get dumped on your doorstep.

I have done my fellowship in a cancer hospital. There is no better place on earth to see the good and bad of opioid therapy. The greatest thing I have learned here is to choose both my patients AND my therapies wisely.

Like it or not, the more you prescribe opioids, the greater the chance that you've been duped or lied to. Think you're too smart to get fooled? Wrong. Think your in-office UDS keeps you safe? Wrong. Is it worth the risk? Sometimes. Like or not, it sure sucks when a bottle of narcotics you prescribed winds up in an evidence bag at the police station (regardless if they are stolen or not). Call me a weenie, but I think about it EVERY time I write for narcotics. That's why I don't like to write for them unless I get CRYSTAL clear feedback from the patient that they are benefitting on stable, low doses. Truth is, I'm probably still getting lied to even with that philosophy.

Nobody ever knocked over a pharmacy to steal Depo-Medrol.

 

[ParaVert]

PAINDR: "Every specialty has there share of difficult patients. Cardiologists do not like to treat angina patients who are not stent candidates or CABG candidates secondary to poor targets. Vascular surgeons are afflicted by some severely vasculopathic patients. Pediatricians have trouble with patients in difficult family and social situations. The list goes on. You would never hear of these doctors giving up on these patients. You freely chose this specialty and owe it to the patients to attempt to try to treat them. You will not be successful with all but you need to try."

REALLY? Vascular surgeons drop people the minute they can't cut anymore. Do you think that cardiologists ramp up narcotics on patients with refractory angina? Try to get a gastroenterologist to take a referral for chronic nausea or a urologist to take on interstitial cystitis. It is misguided to say that every other specialty is full of pious altruists. There are good and bad seeds in every specialty, and most of us fall in the middle of how much frustration we are willing to take. Our pain clinics can quickly become a dumping ground for patients for which there is nothing to do. I just think it is better for everyone to market ourselves as something other than "chronic pain" managers (because we often fail miserably at this) and focus on the problems and patients we can help. You must know when to say you have nothing left to offer. Defeat beats going down with the ship.

 

[mille125]

I strongly disagree with the use of Methadone in CAD patients. I would also avoid the use of Darvocet and Demerol. But if you substitute any other opioid- or if you tried all other opioids without success and documented this and that the Methadone was not the top choice with clearly defined risks/benefits discussed with the patient- then I agree 100%.

sorry steve....those are two different patient scenarios (i now see that it was unclear).....i agree with you on methadone in CAD.......

 

[PainDr]

PAINDR: "Every specialty has there share of difficult patients. Cardiologists do not like to treat angina patients who are not stent candidates or CABG candidates secondary to poor targets. Vascular surgeons are afflicted by some severely vasculopathic patients. Pediatricians have trouble with patients in difficult family and social situations. The list goes on. You would never hear of these doctors giving up on these patients. You freely chose this specialty and owe it to the patients to attempt to try to treat them. You will not be successful with all but you need to try."

REALLY? Vascular surgeons drop people the minute they can't cut anymore. Do you think that cardiologists ramp up narcotics on patients with refractory angina? Try to get a gastroenterologist to take a referral for chronic nausea or a urologist to take on interstitial cystitis. It is misguided to say that every other specialty is full of pious altruists. There are good and bad seeds in every specialty, and most of us fall in the middle of how much frustration we are willing to take. Our pain clinics can quickly become a dumping ground for patients for which there is nothing to do. I just think it is better for everyone to market ourselves as something other than "chronic pain" managers (because we often fail miserably at this) and focus on the problems and patients we can help. You must know when to say you have nothing left to offer. Defeat beats going down with the ship.

That was not my quote, but I don't disagree with it and I don't think anyone said "every other specialty is full of pious altruists". That would be naive. However, when another specialist finds themselves with a pain mgmt issue (angina, interstitial cystitis), it is no longer a cardiology or urology issue and it is entirely appropriate to refer them to you because that is YOUR specialty.

All I'm saying is that we still try to use acute pain techniques to treat some patients with chronic pain in which NOTHING helps. Hasn't everybody seen some of these patients? You do some blocks, you give some meds, their functionality is still poor and their pain scales are still high. Almost without fail, these people still want narcotics even though there is no objective evidence of improvement in their function. Even the pro-opioid posts sound like you'd stop opioids unless the patient proves they are actually getting objective benefit. Sounds good to me too. The problem is when those patients hassle your staff or your referring docs incessantly because you cut them off. It just seems easier to try to tailor your practice to minimize the number of referrals for chronic, intractable whole body pain unresponsive to everything ten other physicians have tried BEFORE they get dumped on your doorstep.

As many of us have said, not everyone is a candidate for opioid therapy and the type of patient you describe certainly is not. However, your average PCP doesn't know how to make that determination and will look to you for guidance. Also, if you arm yourself with strict clinic rules and enforce them, neither you nor the PCP will be hassled. Excessive phone calls to the clinic, aggressive, histrionic or rude behavior are all forms of abuse and are not tolerated. Threatening behavior is extortion until proven otherwise. Every pt signs an opioid agreement and the rules are verbally explained during the first visit. If they don't want to adhere to the rules they are free to go elsewhere and several have. Also, whenever I discharge a pt I immediately call the referring physician to alert them. I've never had a PCP get upset with me for discharging a pt. In fact, they're usually very grateful for the help and are certainly willing to discharge pts who cause trouble.

Like it or not, the more you prescribe opioids, the greater the chance that you've been duped or lied to. Think you're too smart to get fooled? Wrong. Think your in-office UDS keeps you safe? Wrong. Is it worth the risk? Sometimes. Like or not, it sure sucks when a bottle of narcotics you prescribed winds up in an evidence bag at the police station (regardless if they are stolen or not). Call me a weenie, but I think about it EVERY time I write for narcotics. That's why I don't like to write for them unless I get CRYSTAL clear feedback from the patient that they are benefitting on stable, low doses. Truth is, I'm probably still getting lied to even with that philosophy.

You're not a weenie...just paranoid. You should be. I'm sure all of us are getting lied to occasionally. However, I can't justify denying medication to those who really need it and are responsible with it, just because addicts may try to get into my clinic. I know one will sneak in now and then, but they almost always eventually show their true colors. I run a tight ship and they rarely like following the rules. All you can do is protect yourself and use good judgement.

 

[Ligament]

Excellent discussion. I for one plan to write opioids with a zero tolerance opioid agreement policy (explained by myself in person on the first visit and in writing) and with frequent documentation of functional improvement related to opioid use (again explained by myself in person to the patient at the first visit). I think they certainly have a time and place. Just one tool in the box.

I feel that *chronic* opioid consumption can lead to just as many, if not more significant, problems as no chronic opioid consumption. I suspect that we cross the line from help to harm when we do not closely monitor all effects (not just "side effects") of opioids in our patients.

 

[mille125]

PAINDR: "Every specialty has there share of difficult patients. Cardiologists do not like to treat angina patients who are not stent candidates or CABG candidates secondary to poor targets. Vascular surgeons are afflicted by some severely vasculopathic patients. Pediatricians have trouble with patients in difficult family and social situations. The list goes on. You would never hear of these doctors giving up on these patients. You freely chose this specialty and owe it to the patients to attempt to try to treat them. You will not be successful with all but you need to try."





I actually made this quote and you totally missed the point. You have freely decided to dedicate your career to chronic pain management. You are not a medical student or resident who is forced to take the rotation. You freely decided to do this. Therefore, you have a moral and ethical obligation to do what is in the best interest of your patients. IMHO, if you are uncomfortable or unable to do this you need to change specialties.

 

[ParaVert]

I actually made this quote and you totally missed the point. You have freely decided to dedicate your career to chronic pain management. You are not a medical student or resident who is forced to take the rotation. You freely decided to do this. Therefore, you have a moral and ethical obligation to do what is in the best interest of your patients. IMHO, if you are uncomfortable or unable to do this you need to change specialties.[/QUOTE]

Sorry about the misquote, by bad.

The point I am trying to make is that I have NOT dedicated my career to "chronic" pain management. Let's be clear. I, as a physician, am given the lattitude to practice in the manor I see fit. Whether that is doing exclusively procedures (like an interventional radiologist) or stictly meds (like palliative care) or wherever in the middle I prefer, it is MY choice. I think it is rediculous to criticize another physician's practice style simply because you don't agree with it. If I want to do nothing but kyphoplasty all day (I did two and a sacroplasty today), that's my perogative. You want to be a supplier to the neighborhood rave party? That's your perogative.

"Moral and ethical obligation" to do what's best for the patients --- Here's where we agree. Convince me that patients are better off on opioids and I'll change my tune. I work in a cancer hospital and I still believe that opioids are not often associated with clear benefit. It is worse for chronic, non-malignant pain.

Another thing--people knock evidence based medicine in pain. Why? I think that if you look at the existing evidence on both opioids AND procedures, you'd come to my same conclusion. Opioids and injections have both been proven consistantly to do one thing--improve an acute pain condition faster than it would on it's own. They do very little for chronic pain. You think your observations in clinical practice contradict this? Check out Eriksen in Pain (November 2006). Stop fooling yourself into thinking you're helping your chronic pain patients by ramping up the narcotics just because you have nothing else to offer. Stop fooling yourself in thinking that all of your opioid patients are SO much happier and more functional on the drugs. Wishful thinking! They are not. Patients on chronic opiates are less likely to work, overutilize health care monies, and report a lower quality of life than those patients not on opiates. Find me any shred of data to prove otherwise. Pain docs hate EBM because it tells them the truth--chronic pain management is a myth.

Focus on what you can fix, or at least make people feel better while they heal on their own. That's what the evidence supports, and that is what we're best at, and that's what I enjoy. End of story.

 

[Ligament]

Guys, this is a GOOD discussion but getting very close to a fight. Lets cool it down a tad and keep the thread going amicably?

 

[lobelsteve]

I actually made this quote and you totally missed the point. You have freely decided to dedicate your career to chronic pain management. You are not a medical student or resident who is forced to take the rotation. You freely decided to do this. Therefore, you have a moral and ethical obligation to do what is in the best interest of your patients. IMHO, if you are uncomfortable or unable to do this you need to change specialties.

Sorry about the misquote, by bad.

The point I am trying to make is that I have NOT dedicated my career to "chronic" pain management. Let's be clear. I, as a physician, am given the lattitude to practice in the manor I see fit. Whether that is doing exclusively procedures (like an interventional radiologist) or stictly meds (like palliative care) or wherever in the middle I prefer, it is MY choice. I think it is rediculous to criticize another physician's practice style simply because you don't agree with it. If I want to do nothing but kyphoplasty all day (I did two and a sacroplasty today), that's my perogative. You want to be a supplier to the neighborhood rave party? That's your perogative.

"Moral and ethical obligation" to do what's best for the patients --- Here's where we agree. Convince me that patients are better off on opioids and I'll change my tune. I work in a cancer hospital and I still believe that opioids are not often associated with clear benefit. It is worse for chronic, non-malignant pain.

Another thing--people knock evidence based medicine in pain. Why? I think that if you look at the existing evidence on both opioids AND procedures, you'd come to my same conclusion. Opioids and injections have both been proven consistantly to do one thing--improve an acute pain condition faster than it would on it's own. They do very little for chronic pain. You think your observations in clinical practice contradict this? Check out Eriksen in Pain (November 2006). Stop fooling yourself into thinking you're helping your chronic pain patients by ramping up the narcotics just because you have nothing else to offer. Stop fooling yourself in thinking that all of your opioid patients are SO much happier and more functional on the drugs. Wishful thinking! They are not. Patients on chronic opiates are less likely to work, overutilize health care monies, and report a lower quality of life than those patients not on opiates. Find me any shred of data to prove otherwise. Pain docs hate EBM because it tells them the truth--chronic pain management is a myth.

Focus on what you can fix, or at least make people feel better while they heal on their own. That's what the evidence supports, and that is what we're best at, and that's what I enjoy. End of story.[/QUOTE]

Are you Ben Crue?

All of us pain docs need to read his book. This sounds like his viewpoint.

 

[Mister Mxyzptlk]

"I just want a practice that makes me happy and keeps me fed. A procedure-based practice, with minimal opioid management, self-selects patients with more acutely painful conditions. These people are more likely to get better."

Patients seek your services for THEIR benefit, not yours. You do what is best for THEM, not your practice, your lifestyle, or your bank account. If you reverse that relationship you are nothing but the worst kind of predator and a disgrace to medicine.

 

[mille125]

Guys, this is a GOOD discussion but getting very close to a fight. Lets cool it down a tad and keep the thread going amicably?

it is not a fight, it is a discussion

 

[mille125]

I actually made this quote and you totally missed the point. You have freely decided to dedicate your career to chronic pain management. You are not a medical student or resident who is forced to take the rotation. You freely decided to do this. Therefore, you have a moral and ethical obligation to do what is in the best interest of your patients. IMHO, if you are uncomfortable or unable to do this you need to change specialties.

Sorry about the misquote, by bad.

The point I am trying to make is that I have NOT dedicated my career to "chronic" pain management. Let's be clear. I, as a physician, am given the lattitude to practice in the manor I see fit. Whether that is doing exclusively procedures (like an interventional radiologist) or stictly meds (like palliative care) or wherever in the middle I prefer, it is MY choice. I think it is rediculous to criticize another physician's practice style simply because you don't agree with it. If I want to do nothing but kyphoplasty all day (I did two and a sacroplasty today), that's my perogative. You want to be a supplier to the neighborhood rave party? That's your perogative.

"Moral and ethical obligation" to do what's best for the patients --- Here's where we agree. Convince me that patients are better off on opioids and I'll change my tune. I work in a cancer hospital and I still believe that opioids are not often associated with clear benefit. It is worse for chronic, non-malignant pain.

Another thing--people knock evidence based medicine in pain. Why? I think that if you look at the existing evidence on both opioids AND procedures, you'd come to my same conclusion. Opioids and injections have both been proven consistantly to do one thing--improve an acute pain condition faster than it would on it's own. They do very little for chronic pain. You think your observations in clinical practice contradict this? Check out Eriksen in Pain (November 2006). Stop fooling yourself into thinking you're helping your chronic pain patients by ramping up the narcotics just because you have nothing else to offer. Stop fooling yourself in thinking that all of your opioid patients are SO much happier and more functional on the drugs. Wishful thinking! They are not. Patients on chronic opiates are less likely to work, overutilize health care monies, and report a lower quality of life than those patients not on opiates. Find me any shred of data to prove otherwise. Pain docs hate EBM because it tells them the truth--chronic pain management is a myth.

Focus on what you can fix, or at least make people feel better while they heal on their own. That's what the evidence supports, and that is what we're best at, and that's what I enjoy. End of story.[/QUOTE]



nice soliloque on your soapbox.........


give me your address so that my patients can send their letters to you (if I send them to you it is probably a HIPAA violation).

just a few off the top of my head from the last few weeks

1) Mr. X has diffuse degenerative disk disease and spinal stenosis. Has been on methadone 5 mg tid per my request and has returned to work. He saw a doctor with a similar philosophy to paravert three yrs ago. During that time he lost his job and has been on disability. He is grateful.

2) Mrs. Y has left arm RSD following an MVA. Physical therapy has helped improve some of her range of motion. SCS caused dysesthesias. Currently on opana 10 bid, elavil, and ketamine cream with 80% decrease in pain. She saw a doctor similar to paravert and nearly committed suicide.

3) Ms. Z has phantom limb pain since amputation. On oxycontin 20 mg bid. Has not returned to work but she is able to live a pseudonormal life and has started some of the activities that she had given up previously. She saw a doctor similar to paravert three years ago and almost gave up on pain management doctors. She is also very grateful.


I then during the same week, I get:

4) Ms A has secondary fibromyalgia (primary diagnosis of RA/lupus) and takes 20-30 norco per day per PCP (i kid you not). I called her pharmacy prior to her appointment and she has received 900 tablets over the last thirty days between her PCP and the ER. I recommended taper and drug treatment program.

5) Mr. B has had 5 lumbar and two cervical surgeries. On oxycontin 40 mg qid per PCP. Rates pain 9/10. Patient is very deconditioned on exam. I recommended narcotic taper, aquatic exercise, and biofeedback.


Opioids are obviously not for everyone. I hope that Mr X, Mrs. Y, and Ms. Z never run into paravert or tenesma. Who knows maybe they are lying to me and they are not really happy. They took all that time to write their letters for nothing.....

 

[ParaVert]

Mike (Gorback), you know well that there are plenty of predatorail pain docs in our practice area. They are characterized by the relentless pursuit of "interventional chronic pain" treatment. Keep fillin' them with steroid until their adrenals shut down or their insurance denies them. This is a terrible way to practice. It is just as deplorable to do the same with a prescription pad. I'm sure that there are plenty of well minded pain docs who are reading this post who believe that they are doing what is best for their patients, myself included. The reality is that there is no emipiric data to guide our treatment algorithms for chronic pain (acute pain fairly well covered thanks to ISIS and others). We are all convinced of our own BS. Go to any pain meeting, and you'll hear docs talking about their own homebrewed treatment algorithm that "never fails." The real danger in pain management is any doc who thinks they have it all figured out. We must look to EBM for some guidance. Since there is nothing proven to consistently treat chronic pain, perhaps we should not focus on trying to treat chronic pain in vain, but be more honest with ourselves and our patients that we are ill equiped to treat them effectively.

Mike, why is it a travesty to want to tailor my practice in a way I see fit? Am I depriving my patients of a modality with a proven trackrecord (opioids)? No. Is it a sin for the interventional cardiologist to only do procedures and leave the meds to the other guys? No. What about orthopods who only do sports medicine--are they to be damned for not doing trauma call? No. What's wrong with me wanting to do primarily interventional pain (as I have been trained to do), and leave the Vicodin scripts to the PCP--so long as everybody knows what my focus is?

Sure, there aren't a lot of pain docs doing Baclofen pumps, trigeminal RF, kyphoplasty and other invasive stuff, but that's what I got trained in and that's what I want to do. You like med management? Think you're good at it? DO IT.

All I ever said is that we (as a specialty) should focus our efforts on more apropriate management of more appropriate patients. Every person who has posted a patient scenario on opiates has been appropriate and sounds good. I don't criticize the management of any proposed patient. I just don't want to do the lionshare of the prescribing, and I don't have to.

I don't disagree that opiates have their place (short course for acute pain of clearly defined pathology). I'm just giving a counterargument to the myth that (1) individual pain practitioners do a great job of screening out those patients who are abusing/diverting opiates (2) chronic opioid therapy have been shown to benefit a wide cohort of patients (3) Every physician who defines any aspect of pain management has a duty and obligation to believe points 1 and 2, and prescribe opiates to anybody who wants them as long as they don't admit to diversion.

Remember, Pain is also a subspecialty fellowship in Neurosurgery. Nobody criticizes them for only doing procedures. Maybe we need more internists in this field so that we can all find their niche.

 

[drrinoo]

<Pain docs hate EBM because it tells them the truth--chronic pain management is a myth.>

Excellent post, Steve, but I have had misgivings for a long time about the role of EBM in pain medicine, actually the role of EBM in general.

If EBM can be used to study anything in the field of medicine, e.g., drugs, treatment, diagnostic test, workflow processes in a hospital, then it can be used to study the last and final tool, the physician.

DEVIL's ADVOCATE

If the CEO of a large health care insurance company, asked you to produce evidence that physiatry is relevant to the practice of medicine...what would you do?

If this CEO said 1.5-2B per annum (6000+ physiatrists X 250K median salary) could be saved...and furthermore, internists add value because they can treat general medical problems....what would you say?

If the CEO said that (s)he would revoke funding for any CPT codes submitted by physiatrists, unless you produced a single blinded controlled trial whereby one group of chronic pain patients is randomized to physiatrists and the other to internists...and that the only outcomes that would be relevant would be SF-36 or return to work or reduced utilization of outpatients services...and NOT the VAS or patients satisfaction....would you agree?

EBM has crossed over into unfamiliar terrain and it will one day seize upon the last protected vestige in the field of medicine: the physician.

It has already started in a crude, but good early attempt. Recently, NEJM used survey data to ascertain the impact of physician industry relationships.


So, as EBM is used to study less 'biologic' problems and more 'sociological' and 'public health' problems in the field of medicine, we will encounter more negative or lack of efficacy clinical trials.

I still believe that physician autonomy and judgment should play an important role in more 'sociological' problems, such as chronic pain, despite EBM.

 

[Mister Mxyzptlk]

IMHO carving out weakly supported but well-paying modalities like interventions and turning your nose up at opioid prescribing is self-serving and hypocritical. And if you implant pumps then it is the height of hypocrisy to not write for PO opioids on the basis of lack of evidence.

The PCPs do not know how to prescribe opioids. You might as well have them doing blind ESIs in the office too. If you want to defer one modality (prescribing) to someone far less skilled why not also teach the PCPs the rudiments of other modalities like procedures? Then we can have all pain management done poorly and we don't need any pain specialists.

 

[mille125]

IMHO carving out weakly supported but well-paying modalities like interventions and turning your nose up at opioid prescribing is self-serving and hypocritical. And if you implant pumps then it is the height of hypocrisy to not write for PO opioids on the basis of lack of evidence.

The PCPs do not know how to prescribe opioids. You might as well have them doing blind ESIs in the office too. If you want to defer one modality (prescribing) to someone far less skilled why not also teach the PCPs the rudiments of other modalities like procedures? Then we can have all pain management done poorly and we don't need any pain specialists.

absolutely agree with the above

 

[mille125]

<Pain docs hate EBM because it tells them the truth--chronic pain management is a myth.>

Excellent post, Steve, but I have had misgivings for a long time about the role of EBM in pain medicine, actually the role of EBM in general.

If EBM can be used to study anything in the field of medicine, e.g., drugs, treatment, diagnostic test, workflow processes in a hospital, then it can be used to study the last and final tool, the physician.

DEVIL's ADVOCATE

If the CEO of a large health care insurance company, asked you to produce evidence that physiatry is relevant to the practice of medicine...what would you do?

If this CEO said 1.5-2B per annum (6000+ physiatrists X 250K median salary) could be saved...and furthermore, internists add value because they can treat general medical problems....what would you say?

If the CEO said that (s)he would revoke funding for any CPT codes submitted by physiatrists, unless you produced a single blinded controlled trial whereby one group of chronic pain patients is randomized to physiatrists and the other to internists...and that the only outcomes that would be relevant would be SF-36 or return to work or reduced utilization of outpatients services...and NOT the VAS or patients satisfaction....would you agree?

EBM has crossed over into unfamiliar terrain and it will one day seize upon the last protected vestige in the field of medicine: the physician.

It has already started in a crude, but good early attempt. Recently, NEJM used survey data to ascertain the impact of physician industry relationships.


So, as EBM is used to study less 'biologic' problems and more 'sociological' and 'public health' problems in the field of medicine, we will encounter more negative or lack of efficacy clinical trials.

I still believe that physician autonomy and judgment should play an important role in more 'sociological' problems, such as chronic pain, despite EBM.

Insurance companies and the like are all pushing P4P, EBM, electronic records, etc. The ironic thing is that there is NO EVIDENCE that any of these things will help control health care costs.....isnt it ironic

 

[ParaVert]

How can you say that PCP's don't know how to write for opioids? More opioids are written by PCP's than all the pain docs combined. Again, show me some evidence that pain docs are doing a better job of prescribing than PCP's by showing better functional outcomes.

What's wrong with only doing procedures that work? How is it self-serving and hippocritical? I don't understand. When I see a patient with radicular pain, I tell them that if they take some NSAIDS and do some PT, they'll feel better eventually. If I do an ESI, they'll probably feel better faster. I also tell them that if they develop chronic pain, that neither blocks nor meds have proven efficacy. Sure, I may try some blocks and some opiates, but I tell them that it is for short term only.

I agree that opioid pumps are no better than any other route of administration except in side effect profile. That's why I plan to only do baclofen for spasticity or opioid pumps for cancer patients who can't tolerate opioids due to side effects. This approach is well supported by the evidence.

Again, I don't turn my back on the prescribing of opiates, I just have specific indications and end points of therapy that obviously differ from the others on this post. Those indications do not include chronic, intractable lifelong pain. Those patients are better served by intensive cognitive behavioral therapy focusing on coping strategies.



Mille, you posted a few patient scenerios for who you use opioids on and who you stop them on. Why did you stop the opioid on the FBSS on Oxy? Do you have a prejudice against fibromyalgia and FBSS? Those are two of the most common chronic pain diagnoses seen by pain docs. I agree with stopping the opioids on these patients. I would do that because they are not proven to be effective, and that ALL chronic pain patients are deconditioned. Please explain YOUR rational for those you stopped opiates on. Is the dose too high for your comfort zone? Think oxy is too contravertial to prescribe? Couldn't you argue that the patient was just tolerant and needed even more? For those patients that are not diverting, how do you decide when they have failed a trial of opioids? Is your technique supported by any literature?

 

[PainDr]

What's wrong with only doing procedures that work? How is it self-serving and hippocritical? I don't understand. When I see a patient with radicular pain, I tell them that if they take some NSAIDS and do some PT, they'll feel better eventually. If I do an ESI, they'll probably feel better faster. I also tell them that if they develop chronic pain, that neither blocks nor meds have proven efficacy. Sure, I may try some blocks and some opiates, but I tell them that it is for short term only.

How many pts have a single isolated episode of radicular pain or recurrent radicular pain without some baseline pain? So what about long term care? Should they all just file for disability and spend their days in bed? In a perfect world, we'd all be able to "fix" our pts, but in the real world that rarely happens.

 

[mille125]

You are reading too much into it. I do not have a prejudice against fibromyalgia or FBSS. Simply, neither of these patients reported a decrease in pain scores or functional improvement despite being on medium/high dose narcotics for greater than nine months. The first patient actually reported in increase in pain compared to a year ago despite no change in her disease progression. I always taper in this situation as most pain doctors would. Each patient is an individual. There is no magic formula. Use your clinical judgement (that is what you learned in fellowship).

 

[mille125]

I would argue that the strategies adopted by tenesma and paravert are actually based on fear instead of data. If this is true, it is unfortunate...

 

[lobelsteve]

I would argue that the strategies adopted by tenesma and paravert are actually based on fear instead of data. If this is true, it is unfortunate...

I use excessive documentation to qwell my fears. And I write opioids as I see fit, and I stim as I see fit, and I put needles where they need to go in accordance with published literature and accepted techniques.

This is an easy job, but I can't deny my patients the possibility that a treatment may work well for them. THat's why they trial opioids like they trial SCS. I've found that putting my pen down is a most effective tool for stopping opioids. My patients agree.

 

[ParaVert]

I use excessive documentation to qwell my fears. And I write opioids as I see fit, and I stim as I see fit, and I put needles where they need to go in accordance with published literature and accepted techniques.

This is an easy job, but I can't deny my patients the possibility that a treatment may work well for them. THat's why they trial opioids like they trial SCS. I've found that putting my pen down is a most effective tool for stopping opioids. My patients agree.

Steve, that's the best answer I've heard yet. I like the idea of a continuous "trial" of opioids. I guess my question to that is, how do you handle patients who want more opioids even though they haven't met your criteria for success? If you decide that they haven't improved enough for whatever reason, how do you deal with their plea, "but I'm still hurting, doc?" And do you keep seeing them in clinic or do you discharge them? How do you handle their exasperated PCP?

Deb, you're right in that I haven't been exposed much to the highly functional opioid patient. Our opioid patients here are the worst of the worst (you know that well from your fellowship). There is tremendous institutional pressure to continue patients on opioids despite a serious lack of functional improvement. This is true even in patients with stable disease. This has really burned me out on opioid management.


To all those out there who have community based practices with patients on chronic opioids who are really doing better on an objective level, I applaud you. I am greatly encouraged by this. I hope that I have the same in private practice. Yes, I am afraid to prescribe opioids. I am also leary of benzos, hypnotics, and other medications with steet value and abuse potential. We all should be. I hate to hear certain pain docs dismiss the reality that prescribing these meds is a major liability. It is.

That being said, if there is a subset of the pain population that truly benefits long-term from chronic, low, stable doses of these meds, I'll use them, sparingly and cautiously. God knows I sure haven't seen much of that thus far.

No matter where any of us fall on the opioid debate, it's not about the money, it's not about being self-rightious, it is just about keeping both our patients and ourselves safe and better off.

 

[lobelsteve]

Steve, that's the best answer I've heard yet. I like the idea of a continuous "trial" of opioids. I guess my question to that is, how do you handle patients who want more opioids even though they haven't met your criteria for success?


That being said, if there is a subset of the pain population that truly benefits long-term from chronic, low, stable doses of these meds, I'll use them, sparingly and cautiously. God knows I sure haven't seen much of that thus far.
.

I just say no. Typical scenario:

Pt: Dr. Lobel, my pain is not relieved on this medication, can I have more than this?

Me: No. (smiling, long pause)

Pt: Why not?

Me: The dose is high enough that we would have seen a difference. We can change from X to Y and see if that works. There are over 20 receptors that these medications can bind to to produce pain relief, and maybe you just don't have enough of the receptor for medication X.

Pt: But when I took 3 at a time of X, I did feel better.

Me: I'll make a note of your ABERRANT behavior in my chart, please take your medication as directed or I'll have to refer you to an addiction medicine specialist and I may not be able to treat you with the strongest medications possible.

Pt: I'm sorry, here is the rest of medication X in the pill bottle.

Me: 1 point off, 1 point back on= You're even for the day. In addition to changing medicine, how is PT(or home exercise program going), are you using your RS4i, and where are we in your diagnostic and theraputic treatment algorithm?

Pt: I want the SCS, I watched the video.

Me: I need to send you to a clinical psychologist to make sure you are: RIGHT PATIENT, RIGHT PROCEDURE, RIGHT TIME.

Pt: I hope we can do it soon. I'm going on a cruise to ZZZ and I want to be able to get about and off the boat.




I don't know about you, but my patients take more cruises than there are cruise ships. I thought they were all lying to me until I starting asking for souvenirs. Just as long as the new pt going on the antarctic cruise doesn't bring me back a penguin.

 

[Tenesma]

hi...

1) there is no such thing as the "perfect" pain doctor... there are pain doctors who only do prolotherapy, there are pain doctors who only do med. management, there are pain doctors who only do stims, there are pain doctors who only do procedures, there are pain doctors who do a tiny bit of everything, there are pain doctors who only do biofeedback, there are pain doctors who only do IMEs....

so this concept that every pain doctor needs to prescribe narcotics is a bunch of baloney.

2) narcotics are appropriate in a select few patients.... just ask yourself at the end of the day which patients you felt really, really "good" about writing narcotics.... those are probably the only appropriate patients, everybody else should be weaned off... we owe it to our patients, we owe it to ourselves and our communities...

3) i don't implant pumps unless the patient has terminal cancer - and then i only use the codman's (cheaper)...

4) sure the patients who get narcotics are going to write thank you letters... i am not surprised... if you are going to base your medical decisions based on the number of thank you letters you get, then i predict many more narcotic prescriptions in your future

 

[Mister Mxyzptlk]

This type of argument relies on the assumption that a questionable ethic is validated by the frequency of its commission.

Since there are pain doctors who won't prescribe narcotics it's ok to not prescribe narcotics.

Since there are people who cheat on their taxes it's ok if you want to cheat on your taxes.

Since there are people who fly jets into tall buildings . . .

This is formally known as "Appeal to Common Practice". It's the old "Everyone is doing it" argument, and your mother used to respond appropriately to this with, "If Fred jumped off a cliff would you do it too?"

The proposition of an argument must be justified on its own merits. What others are doing, and the conclusions they may have reached, mean nothing.

 

[Tenesma]

gorback - that is an unusual way to twist my words around... but that is okay - because i always enjoy what you write

my point is/was that there are different ways to practice pain - it is a broad field... if a physician chooses to focus on just a part of that field doesn't mean what they are doing is right or wrong, it just means that they chose to focus on one part of that field.... if economically they can survive then all the power to them...

i suspect that those who do prescribe narcotics feel that if they are doing it then everybody else should help carry the burden - and that my friend, is a flawed philosophy/logic in my opinion...

in fact i know quite a few pain guys who prescribe narcotics ONLY so that they can get procedure referrals from specific PCPs...

let's have a show of hands - if you could never write another opioid again, but make recommendations to PCPs on who is and who isn't appropriate, and give occasional suggestions on opioid management to those PCPs, would you go for it?

the reality is that we don't prescribe all the narcotics in this country - not by far - in fact we underprescribe as a group compared to PCPs.... i was speaking to the Fentora rep (basically legal heroin) and he told me that 95% of his fentora is being prescribed for chronic back pain (does that make sense???) and that over >60% of prescribing physicians are PCPs - pain doctors are only 20% of the market in this area....

 

[Mister Mxyzptlk]

gi was speaking to the Fentora rep (basically legal heroin) and he told me that 95% of his fentora is being prescribed for chronic back pain (does that make sense???) and that over >60% of prescribing physicians are PCPs - pain doctors are only 20% of the market in this area....

Which is why PCPs shouldn't be writing opioid prescriptions for chronic pain any more than they should be learning to do ESIs at weekend courses.

 

[mille125]

hi...

1) there is no such thing as the "perfect" pain doctor... there are pain doctors who only do prolotherapy, there are pain doctors who only do med. management, there are pain doctors who only do stims, there are pain doctors who only do procedures, there are pain doctors who do a tiny bit of everything, there are pain doctors who only do biofeedback, there are pain doctors who only do IMEs....

so this concept that every pain doctor needs to prescribe narcotics is a bunch of baloney.

2) narcotics are appropriate in a select few patients.... just ask yourself at the end of the day which patients you felt really, really "good" about writing narcotics.... those are probably the only appropriate patients, everybody else should be weaned off... we owe it to our patients, we owe it to ourselves and our communities...

3) i don't implant pumps unless the patient has terminal cancer - and then i only use the codman's (cheaper)...

4) sure the patients who get narcotics are going to write thank you letters... i am not surprised... if you are going to base your medical decisions based on the number of thank you letters you get, then i predict many more narcotic prescriptions in your future

actually there is a such thing as the perfect pain doctor....it just isn't you.....

 

[mille125]

hi...

1) there is no such thing as the "perfect" pain doctor... there are pain doctors who only do prolotherapy, there are pain doctors who only do med. management, there are pain doctors who only do stims, there are pain doctors who only do procedures, there are pain doctors who do a tiny bit of everything, there are pain doctors who only do biofeedback, there are pain doctors who only do IMEs....

so this concept that every pain doctor needs to prescribe narcotics is a bunch of baloney.

2) narcotics are appropriate in a select few patients.... just ask yourself at the end of the day which patients you felt really, really "good" about writing narcotics.... those are probably the only appropriate patients, everybody else should be weaned off... we owe it to our patients, we owe it to ourselves and our communities...

3) i don't implant pumps unless the patient has terminal cancer - and then i only use the codman's (cheaper)...

4) sure the patients who get narcotics are going to write thank you letters... i am not surprised... if you are going to base your medical decisions based on the number of thank you letters you get, then i predict many more narcotic prescriptions in your future

There are an equal number of letters for those that were started/continued on narcotics and those that were tapered. It is ludacrous to say that medical decisions were made based on thank you letters..........Remember, in the end you are there to help people. If there are other things in the agenda (ie your bank account, mercedes, your own fear, etc), then you need to step back and reevaluate your approach.

 

[mille125]

actually there is a such thing as the perfect pain doctor....it just isn't you.....

i retract this statement because it is just plain mean.......

 

[PainDr]

2) narcotics are appropriate in a select few patients.... just ask yourself at the end of the day which patients you felt really, really "good" about writing narcotics.... those are probably the only appropriate patients, everybody else should be weaned off... we owe it to our patients, we owe it to ourselves and our communities...

80-90% of my population are elderly pts with obvious spinal pathology. Most of them, even some with neuro deficits, are not surgical candidates. They can only have so many blocks each year and I can only do so much with RF and stims, so opioids help them get on with their lives. In these pts, I always feel "really, really good" about helping them with narcotics. They're able to hobble around, go to their bridge games, go to Wal-Mart, play with their grandchildren, etc. THIS is what I owe to my pts, myself and my community.

...Remember, in the end you are there to help people. If there are other things in the agenda (ie your bank account, mercedes, your own fear, etc), then you need to step back and reevaluate your approach.

I couldn't agree more. It's obvious that some posters either don't understand our point of view (which I find hard to believe) or don't want to admit that they might have other, more selfish motives. I've only been in practice a short time, but haven't become greedy or jaded or scared and pray I never will. It's obvious that ours is a specialty divided, which is unfortunate, because utimately, it is our pts who will suffer the consequences.

 

[Tenesma]

mille - that was quite mean.... but i know that it is easy to be mean in a forum when all of us are blanketed by anonymity...

i understand your frustration with my point of view - that is okay - i hope you can look at all of my posts and read through the lines that sometimes i can be a bit sarcastic...

i never said that writing narcotics is evil or wrong.... i just don't write narcotics period - but will gladly recommend it (if indicated) to the PCP... if the patient is well controlled on oxycodone then why come see me?

but the notion that narcotics should be our fall back is a weak answer to chronic pain...

 

[mille125]

mille - that was quite mean.... but i know that it is easy to be mean in a forum when all of us are blanketed by anonymity...

i understand your frustration with my point of view - that is okay - i hope you can look at all of my posts and read through the lines that sometimes i can be a bit sarcastic...

i never said that writing narcotics is evil or wrong.... i just don't write narcotics period - but will gladly recommend it (if indicated) to the PCP... if the patient is well controlled on oxycodone then why come see me?

but the notion that narcotics should be our fall back is a weak answer to chronic pain...

i said that i was sorry and i meant it...........