Outpatient Pain Clinic Questions

[Squajada21]

Ive looked on the web for some information like Beckersspine, etc. I will (hopefully) be matching into a PMR residency this year and then will apply for pain fellowships. I have wanted to do pain for a few years as I think pain is a very unique aspect of our physiology and I understand from my personal experiences how just a little relief of chronic pain can improve your quality of life. I chose PM&R due to MSK knowledge gained in residency as well vs other specialties that can lead to ACGME pain fellowships.

I was wondering how feasible is it to start a multidisciplinary pain practice (PT, aquatic therapy, psychotherapy) that does not manage the chronic opiods (allow the PCP to manage) unless they are not on any as well as having a fluro on site?

Or is it even possible to start such clinic and expand it by building an ambulatory surgical center and having partners that do other surgical procedures?

Also, do pain physicians do a lot of regernative medicine in thier clinics for joint pain, tendinopathies?

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[Ligament]

Ive looked on the web for some information like Beckersspine, etc. I will (hopefully) be matching into a PMR residency this year and then will apply for pain fellowships. I have wanted to do pain for a few years as I think pain is a very unique aspect of our physiology and I understand from my personal experiences how just a little relief of chronic pain can improve your quality of life. I chose PM&R due to MSK knowledge gained in residency as well vs other specialties that can lead to ACGME pain fellowships.

I was wondering how feasible is it to start a multidisciplinary pain practice (PT, aquatic therapy, psychotherapy) that does not manage the chronic opiods (allow the PCP to manage) unless they are not on any as well as having a fluro on site?

Or is it even possible to start such clinic and expand it by building an ambulatory surgical center and having partners that do other surgical procedures?

Also, do pain physicians do a lot of regernative medicine in thier clinics for joint pain, tendinopathies?

Having a clinic with onsite PT, aquatherapy, psych is very very difficult, as those things barely pay the bills. Some folks have this, but it is very rare. If they do have it, is is usually (not always) paid for by opioid prescriptions which pay for in house utox testing which pays for the pain psych...

 

[drusso]

Having a clinic with onsite PT, aquatherapy, psych is very very difficult, as those things barely pay the bills. Some folks have this, but it is very rare. If they do have it, is is usually paid for by opioid prescriptions which pay for in house utox testing which pays for the pain psych...

A couple things to make the endeavor more cost effective: 1) Use MSW's instead of PhD/PsyD level therapists. 2) Use athletic trainers or LMT's instead of DPT's. 3) Use drug-alcohol counselors as care coordinators/health coaches.
Most health plans don't consider comprehensive pain management as an essential health benefit.

Always remember drusso's maxim: "If you give away your services, then people will value them as worthless."

 

[Ducttape]

i would suspect that those clinics that are fueled by opioid prescriptions wouldnt bother with those ancillary services. sucks away money. why bother?

i know drusso will disagree, but possibly hospital systems are more likely to have the capacity, financial resources and benefits to fund such a plan, and even they will have some difficulty.

in my neck of the woods, psychologists are not available to Medicaid. only MSW or therapists.

 

[RM38]

I may be only a fellow, but I have talked to many PP Pain docs and I think you may have a tough time starting a new private practice and not prescribe opioids. Many PCPs are now unwilling to write for opioids at all in the current climate with all of the issues surrounding pain medications, so they won't send you their patients if that is their policy. Unless you work for an big Ortho group that will send you a lot of internal referrals and doesn't want you want to manage medications, I think that it would be hard to build a solid referral base to support your salary much less a bunch of other peripheral services. If you want to get into regenerative stuff there are definitely a number of pain docs whom are getting involved in that area though.

 

[DrCommonSense]

I may be only a fellow, but I have talked to many PP Pain docs and I think you may have a tough time starting a new private practice and not prescribe opioids. Many PCPs are now unwilling to write for opioids at all in the current climate with all of the issues surrounding pain medications, so they won't send you their patients if that is their policy. Unless you work for an big Ortho group that will send you a lot of internal referrals and doesn't want you want to manage medications, I think that it would be hard to build a solid referral base to support your salary much less a bunch of other peripheral services. If you want to get into regenerative stuff there are definitely a number of pain docs whom are getting involved in that area though.

I think pain docs should be the ones managing the opioids overall with UDS, risk stratification systems and monitoring systems to determine if the patient is getting opioids elsewhere.

I dont think PCPs are equipped for this level of scrutiny that is of utmost importance these days with the narcotic issues.

 

[RM38]

Agreed. Most of the high dose oxy with soma, ambien and xanax combos that come to us are from PCPs. Many of them get pressured into doing things that they really shouldn't by patients until they realize they are in way too deep. Then of course they send them to us and we have to have the conversation with the patient about why we can't/shouldn't continue that combo. Many aren't ever checking UDS and LCMS or even looking at the PMP. Even if they did look at a LCMS, a good number likely wouldn't know how to interpret it properly unless it specifically said positive for cocaine, heroin etc. We have the training to perform all the appropriate procedures as well as manage the medications. The medication part can be a PTA sometimes, but that is part of what we are the experts in. Can you imagine a cardiologist that will do various procedures but then won't manage a patient's medications for that condition? I can't, and if I were a PCP I sure as heck wouldn't want to send anyone to that person.

 

[DrCommonSense]

Agreed. Most of the high dose oxy with soma, ambien and xanax combos that come to us are from PCPs. Many of them get pressured into doing things that they really shouldn't by patients until they realize they are in way too deep. Then of course they send them to us and we have to have the conversation with the patient about why we can't/shouldn't continue that combo. Many aren't ever checking UDS and LCMS or even looking at the PMP. Even if they did look at a LCMS, a good number likely wouldn't know how to interpret it properly unless it specifically said positive for cocaine, heroin etc. We have the training to perform all the appropriate procedures as well as manage the medications. The medication part can be a PTA sometimes, but that is part of what we are the experts in. Can you imagine a cardiologist that will do various procedures but then won't manage a patient's medications for that condition? I can't, and if I were a PCP I sure as heck wouldn't want to send anyone to that person.

Correct.

The person who just wants to do "procedures" but drop the narcotic issue on the PCPs isn't a good pain physician in my opinion and mostly wants to just take advantage of the system.

It's exactly like the cardiologist who would be like: "I'll take all the highly lucrative stent procedures but you can manage the CHF yourself". Just looks greedy and unethical.

Managing these medications is an ESSENTIAL practice of a good multidisciplinary practitioner (just as PT, Behavorial Therapy, etc).

Pain Physicians should be able to determine which patients are high risk for addiction and act accordingly as an essential public health issue to control the narcotic problem in the community.

The can still make a good living ethically while actually helping the community PCPs out.

 

[nvrsumr]

I write no narcotics and have had that philosphy for years at my solo pain practice. Countless lives undoubtable saved from addiction and its societal reprecussions by being a "bad pain physician" and not taking the easy road.

 

[Taus]

Correct.

The person who just wants to do "procedures" but drop the narcotic issue on the PCPs isn't a good pain physician in my opinion and mostly wants to just take advantage of the system.

It's exactly like the cardiologist who would be like: "I'll take all the highly lucrative stent procedures but you can manage the CHF yourself". Just looks greedy and unethical.

Managing these medications is an ESSENTIAL practice of a good multidisciplinary practitioner (just as PT, Behavorial Therapy, etc).

Pain Physicians should be able to determine which patients are high risk for addiction and act accordingly as an essential public health issue to control the narcotic problem in the community.

The can still make a good living ethically while actually helping the community PCPs out.

Eh. No way near same thing as cardiac meds. Patients NEED their cardiac meds and deserve expert care with managing them. Very few patients with pain "need" opioids. Prescribing opioids because it's good for business may be reality for some but it also highly inappropriate. Expertly "managing" opioids should include very little (though not zero) prescribing. Don't do anything you're not comfortable doing...


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[DrCommonSense]

I write no narcotics and have had that philosphy for years at my solo pain practice. Countless lives undoubtable saved from addiction and its societal reprecussions by being a "bad pain physician" and not taking the easy road.

I doubt you have "saved" any lives but are mostly just pushing the management off on the PCPs.

Aggressively titrating down dosages, managing UDS findings and watching narcotic medications that have already been started by PCPs is a very important part of the job. This saves far more lives then just ignoring the patients on high dosages of narcotic medications started by PCPs that have gotten in trouble .

Doing a few injections on this problem patient population isn't going to help alleviate this problem.

PCPs rightfully decide not to send patients to those practitioners compared to the ones who manage this problem aggressively.

I just don't see this practice being ethical.

 

[DrCommonSense]

Eh. No way near same thing as cardiac meds. Patients NEED their cardiac meds and deserve expert care with managing them. Very few patients with pain "need" opioids. Prescribing opioids because it's good for business may be reality for some but it also highly inappropriate. Expertly "managing" opioids should include very little (though not zero) prescribing. Don't do anything you're not comfortable doing...


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It has nothing to do with "needing" opioids, it has to do with fixing the problem that PCPs often get themselves into with difficult patients.

You conflate my stance as "prescribing opioids" for "business", however, my argument is to titrate many of these people DOWN from already higher dosages. Ergo, it is "bad" for "business" by that logic due to upsetting patients who get less narcotics and not just performing injections on people who are just high narcotic users with psych issues like most "non prescribing" PMR spine/Pain Docs will do.

Just keeping your head down and pretending a problem PCPs have gotten themselves into doesn't help the society, PCPs, etc.

Most of the "non prescribing" PMR spine/Pain guys will still inject the patients that are on ridiculous dosages of narcotics to get financial benefit but when that doesn't help (which it never will for a high narcotic user), they will just say to the PCP something along the lines of "sorry, nothing else I can do for you".



Ethical pain docs/PMR spine docs who don't "believe in narcotics" shouldn't do injections on high narcotic users that will clearly not benefit from such procedures. However, we all know that isn't the case right?

We all have seen the type that will do a few injections on those patients until their insurance limit is met and then throw these patients off on the PCP/another pain doc saying "sorry, nothing I can do for you".

How is a patient who is on >100 MEQ of morphine going to benefit from a few LESI treatments without working to titrate them down and have them undergo PT, Behavorial for psych, etc.?

 

[Taus]

I'll ignore the personal swipe (as you have no clue and make baseless assumptions on how I practice). The work you do to take on and titrate down high dose opioids as part of a multimodal plan is needed and I'm sure appreciated. I'm quite content not to.


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[DOctorJay]

I'll ignore the personal swipe (as you have no clue and make baseless assumptions on how I practice). The work you do to take on and titrate down high dose opioids as part of a multi faceted plan is great, needed and I'm sure appreciated. I'm quite content not to.


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At this point in my career I'm happy to provide recommendations on how the PCP who created the problem can go about solving this problem. I'm simply not interested in assuming the risk these patients pose to my license. Once doses are appropriate and the patient is no longer hyperalgesic I may then consider interventional approaches and multimodal therapy.

For the patients who transfer into our system after moving here I tell the PCPs to get those patients to an addictionologist and not to prescribe them their astronomical doses. Those patients don't belong in my office. I don't have an x-waiver. There are docs in our system who have it.

Some referring docs are starting to come around. If you're the go to guy for all the addicts then that is the practice you've built. Nothing wrong with that and clearly there is a need. I appreciate learning about all the different practice models here. I'm simply trying to stick with Pain Management.


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[Dr. Ice]

I have seen anesthesia pain docs trade narcs for procedures. It's like common place aren't my parts. I've also directly observed anesthesia pain docs do procedures because they wanted time at my surgical center and I can tell you many have no business putting a needle near anyone's spine. Let's not make this a primary speciality pissing contest as I'm sure all of this can be said about pmr pain docs as well. Bad docs are like bad fruit..there's a lot of them.

 

[DrCommonSense]

I have seen anesthesia pain docs trade narcs for procedures. It's like common place aren't my parts. I've also directly observed anesthesia pain docs do procedures because they wanted time at my surgical center and I can tell you many have no business putting a needle near anyone's spine. Let's not make this a primary speciality pissing contest as I'm sure all of this can be said about pmr pain docs as well. Bad docs are like bad fruit..there's a lot of them.

I was including anesthesia docs as "pain docs". I just included PMR spine as well for pure interventional physicians that can't be "bothered" with narcs.

Nothing to do with a PMR vs Anesthesia post. Sorry if it was confusing.

 

[DrCommonSense]

I'll ignore the personal swipe (as you have no clue and make baseless assumptions on how I practice). The work you do to take on and titrate down high dose opioids as part of a multimodal plan is needed and I'm sure appreciated. I'm quite content not to.


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The personal swipe was actually addressed towards the other post whereby it was implied that if I manage narcs, I am basically a pill mill or some other similar analogous situation.

 

[Squajada21]

Thanks for the responses.
With the increasing use of biologics for pain. Do pain medicine specialitsts promote the use of modalities such as PRP, Stem Cell for painful joints or do orthopedic clinic usually handle such. Ive done 3 ortho rotations and 2 PMR during 4th year and saw most orthopedic physisicans did not handle/perform biologics much and either referred or had a sport medicine clinic attached which was PMR or FM physicians with a sports medicine fellowship perform such procedures.

If one to have a private practice pain management clinic, could you market yourself to all the OBGYN, FM, IM doctors and state that you can help with such pain and delay a TKA or THA, or spinal fusion with a disc nucleoplasty, etc? Or would this encroach on the other specialists terriotry and cause a **** storm?

With the many new pain procedures now I feel like that opioid prescription should go down after a patient gets releif from a RFA, ESI, etc. Perhaps you could use a multi-modal pharm program that does not use opiods ( Tramadol, Tylenol, NSAIDs, Lyrica, etc and I think Ive seen NMDA anatoginsts now are showing good promise with pain treatment)?

Opiods have thier uses and am not saying never to prescribe them or if you do that you are a "pill pusher". I beleive that is why we have these newer procedures to help stop the opioid prescriptions?

Sorry for the naive med student questions.

 

[neutro]

Thanks for the responses.
With the increasing use of biologics for pain. Do pain medicine specialitsts promote the use of modalities such as PRP, Stem Cell for painful joints or do orthopedic clinic usually handle such. Ive done 3 ortho rotations and 2 PMR during 4th year and saw most orthopedic physisicans did not handle/perform biologics much and either referred or had a sport medicine clinic attached which was PMR or FM physicians with a sports medicine fellowship perform such procedures.

If one to have a private practice pain management clinic, could you market yourself to all the OBGYN, FM, IM doctors and state that you can help with such pain and delay a TKA or THA, or spinal fusion with a disc nucleoplasty, etc? Or would this encroach on the other specialists terriotry and cause a **** storm?

With the many new pain procedures now I feel like that opioid prescription should go down after a patient gets releif from a RFA, ESI, etc. Perhaps you could use a multi-modal pharm program that does not use opiods ( Tramadol, Tylenol, NSAIDs, Lyrica, etc and I think Ive seen NMDA anatoginsts now are showing good promise with pain treatment)?

Opiods have thier uses and am not saying never to prescribe them or if you do that you are a "pill pusher". I beleive that is why we have these newer procedures to help stop the opioid prescriptions?

Sorry for the naive med student questions.

1) I doubt any one procedure by itself in pain medicine is 100% curative. Lumbar RFA is probably the best procedure we have. ESIs/ TFESI have moderate-good benefit but short term in select patients. Other procedures depend on patient's evaluation, appropriateness of procedure for that patient and clinical condition, i.e. the context and basically "does this patient want to get better".
2) Procedures by themselves will never replace the need to recognize and treat cognitive dysfunction in a pain patient. Maybe injections work 30% of the time, maybe 30% is placebo effect from actually giving a damn about the patient's complaints, maybe 30% is medications and other modalities, maybe the rest is the patient's effort - that in essence is multidisciplinary pain management.
3) In pain management - you can choose what you want to do. I know doctors who dont touch the neck and are experts in back injections, nor do any medication management. I know docs who dont do a single injection, but meds only (and they are well respected). The current model is somewhere in between. Some docs do anesthesia and inpatient pain mgt, peri-operative pain mgt, and blocks only and cancer pain mgt (i.e. LEGITIMATE physiological pain issues - not psychosocial issues that dominate chronic pain mgt).
4) Re: biologics and PRP, I am still waiting on evidence for it to be convinced personally. But yes, some patients will benefit from PRP injection for lateral epicondylitis etc. The indications are very few and selective.
5) Its a shame that insurance company does not approve ketamine and lidocaine infusions for neuropathic pain - it is approved in Canada and many European countries - and those can be great therapies, atleast as adjuncts. We do have an NMDA modulating drug - good old methadone. But it takes skill and vigilance to manage that medication.