Pain docs turning away chronic pain patients?

[John1513]

greetings!

Do dentists turn away patients with cavities?

How about OBGYNs turning away pregnant patients?

How come Pain Medicine docs are refusing to care for patients with chronic pain?

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[gdub25]

Trying to think of a good analogy....

Take the dentist seeing a patient with cavities but the patient telling the dentist that candy is the only thing that gets his teeth to feel clean and despite all recommendations and science to the contrary the patient just knows that all they need is more candy to fix their teeth and in fact, another dentist told them to continue eating candy but said they had to get ongoing care somewhere esle.

Our group doesn’t refuse or screen any referrals. We see whoever is sent our way. However, every single day I tell patients that the treatment I advise is to wean their pills and do other treatments, or, no treatment at all because pain pills not only don’t.help but in fact make things worse in many cases. Those patients likely go back to PCPs and tell them we won’t help them but in fact we tried, they just didn’t like our plan.

 

[anonperson]

greetings!

Do dentists turn away patients with cavities?

How about OBGYNs turning away pregnant patients?

How come Pain Medicine docs are refusing the care for patients with chronic pain?

I'm an OB GYN and I have turned away pregnant patients for the following reasons:

Too high risk
Non compliant
Significant drug use history
Etc

Just because it's apart of your specialty doesn't mean you become a dumping ground

 

[drpainfree]

greetings!

Do dentists turn away patients with cavities?

How about OBGYNs turning away pregnant patients?

How come Pain Medicine docs are refusing the care for patients with chronic pain?

If you are asking this question, you haven't seen enough PAIN patients

 

[lobelsteve]

Somewhere along the way everyone forgot pain and addiction are very different things. There are even different fellowships.

 

[Aether2000]

I may have seen my last pain patient ever yesterday. A guy who is taking 100mcg/hr fentanyl plus oxycodone 80mg a day for low back pain. The family doc is nervous about prescribing that much with new state opioid prescribing laws beginning today. Never had PT, never had injections or any other significant therapy- just drugs, drugs, drugs for years. We accepted the patient into the practice I was covering, but not for opioid prescribing. It is the inappropriate prescribing of opioids that has made pain medicine a cesspool and a dumping ground. This is the reason why pain physicians do not accept the mistreated patients subjected to the substandard care of amateurs who have not kept up with current medical literature about opioids. Pain clinics are expected by other physicians to take over and continue outrageous prescribing patterns, or to become detox clinics. This is not why pain physicians went into pain medicine- to deal without other doctor's screwups.

 

[SommeRiver]

I refuse ppl not infrequently. This is a dumb thread.

 

[Ducttape]

greetings!

Do dentists turn away patients with cavities?

How about OBGYNs turning away pregnant patients?

How come Pain Medicine docs are refusing the care for patients with chronic pain?

“We” are not turning away chronic pain patients.

We are turning away substance use disordered and chemically addicted individuals who should be treated in a multidisciplinary substance abuse clinic or chemical dependency practice.

 

[John1513]

Hello all: thank you for your response!!! Very enlightening!

1) this is not a stupid thread, but a very real everyday issue

2) I am very aware of Pain med fellowship vs Addiction Med fellowship —- check this out:


- addiction medicine is NOT about weaning the patient off of opioids or finding ways to target their root cause of pain. The motto of addiction medicine is “YOU WOULDNT DENY A DIABETIC THEIR INSULIN, WOULD YOU?” Imagine my dismay learning all this, especially from an Osteopathic medicine background.

3) the ultimate WTF moment regarding all this was when I sent a chronic pain patient to a pain management group and their Assessment and Plan was “this patient should go see a Pain doctor..”. I was so confused. I called the office and checked the referral — indeed it was to a Pain Management group. Finally got to the bottom of it: they didn’t want to see chronic pain patients.

4). Dumping ground - I know all about this too. Neuoromusculomedicine encompasses non surgical ortho, rheum, and sports med — somehow th chronic pain patients find their way to us too.

5) there definitely needs to be more conversation between Pain Mgmt and primary care — especially now with the national reaction and extra metrics/widgets in place now

6) definitely frustration on both ends, primary care and pain

7) thank you all again for responding

 

[drusso]

Hello all: thank you for your response!!! Very enlightening!

1) this is not a stupid thread, but a very real everyday issue

2) I am very aware of Pain med fellowship vs Addiction Med fellowship —- check this out:


- addiction medicine is NOT about weaning the patient off of opioids or finding ways to target their root cause of pain. The motto of addiction medicine is “YOU WOULDNT DENY A DIABETIC THEIR INSULIN, WOULD YOU?” Imagine my dismay learning all this, especially from an Osteopathic medicine background.

3) the ultimate WTF moment regarding all this was when I sent a chronic pain patient to a pain management group and their Assessment and Plan was “this patient should go see a Pain doctor..”. I was so confused. I called the office and checked the referral — indeed it was to a Pain Management group. Finally got to the bottom of it: they didn’t want to see chronic pain patients.

4). Dumping ground - I know all about this too. Neuoromusculomedicine encompasses non surgical ortho, rheum, and sports med — somehow th chronic pain patients find their way to us too.

5) their definitely needs to be more conversation between Pain Mgmt and primary care — especially now with the national reaction and extra metrics/widgets in place now

6) definitely frustration on both ends, primary care and pain

7) thank you all again for responding

Tha

@John1513 Caring for these patients is resource and labor intensive work and there is not adequate payment for the time and infrastructure required to manage them in a longitudinal fashion.

Further, you have to distinguish between "Pain-Addicts" ie people with a mixture of medicalized suffering and attachment to chemicals versus the psychologically normal people who are experiencing a nociceptive event (altered comfort). If you're well-resourced and have a burner down the back of your leg, a refractory case of tennis elbow, or a clicky knee that swells after a few matches of tennis then the World is Your Oyster...

If you are married to a molecule, lack adequate funding, are fixated on disability, and drug-seeking then you'll probably get the message that "there is no room at the Inn." The fact of the matter is that absent revenue shifting from other service lines (like a site of service differentials) the work of seeing these kind of patietns doesn't pay for itself on its own merits and a practitioner could be busy all day seeing these kind of patients and still go broke.

The patient you're describing in the OP likely meets DSM-V criteria for Opioid Use Disorder-Mild and probably scores high on the Pain Catastrophizing Scale. I would screen for Fibromyalgia. Once appropriately labeling them as having Opioid Use Disorder and Fibromyalgia they can be expeditiously dispositioned. It's also crucially important to make sure that the diagnoses of Opioid Use Disorder and Fibromyalgia are prominently recognized in their medical chart and EHR so that other health care providers don't go down the rabbit hole of engaging with them in their neuroses and obsessions about pain and opioids.

 

[painfree23]

I may have seen my last pain patient ever yesterday. A guy who is taking 100mcg/hr fentanyl plus oxycodone 80mg a day for low back pain. The family doc is nervous about prescribing that much with new state opioid prescribing laws beginning today. Never had PT, never had injections or any other significant therapy- just drugs, drugs, drugs for years. We accepted the patient into the practice I was covering, but not for opioid prescribing. It is the inappropriate prescribing of opioids that has made pain medicine a cesspool and a dumping ground. This is the reason why pain physicians do not accept the mistreated patients subjected to the substandard care of amateurs who have not kept up with current medical literature about opioids. Pain clinics are expected by other physicians to take over and continue outrageous prescribing patterns, or to become detox clinics. This is not why pain physicians went into pain medicine- to deal without other doctor's screwups.

So what did you offer him?

 

[SommeRiver]

@John1513 It's also crucially important to make sure that the diagnoses of Opioid Use Disorder and Fibromyalgia are prominently recognized in their medical chart and EHR so that other health care providers don't go down the rabbit hole of engaging with them in their neuroses and obsessions about pain and opioids.

Homerun

 

[Aether2000]

We offered him PT, facet injections, and told him to engage in yoga. Also that he should return to his primary care and be weaned slowly off opioids over 4 months. He was not amused.

 

[244913]

Hello all: thank you for your response!!! Very enlightening!

1) this is not a stupid thread, but a very real everyday issue

2) I am very aware of Pain med fellowship vs Addiction Med fellowship —- check this out:


- addiction medicine is NOT about weaning the patient off of opioids or finding ways to target their root cause of pain. The motto of addiction medicine is “YOU WOULDNT DENY A DIABETIC THEIR INSULIN, WOULD YOU?” Imagine my dismay learning all this, especially from an Osteopathic medicine background.

3) the ultimate WTF moment regarding all this was when I sent a chronic pain patient to a pain management group and their Assessment and Plan was “this patient should go see a Pain doctor..”. I was so confused. I called the office and checked the referral — indeed it was to a Pain Management group. Finally got to the bottom of it: they didn’t want to see chronic pain patients.

4). Dumping ground - I know all about this too. Neuoromusculomedicine encompasses non surgical ortho, rheum, and sports med — somehow th chronic pain patients find their way to us too.

5) their definitely needs to be more conversation between Pain Mgmt and primary care — especially now with the national reaction and extra metrics/widgets in place now

6) definitely frustration on both ends, primary care and pain

7) thank you all again for responding

Tha

Don't start your patients on opioids for chronic pain. If you do, don't ever expect anyone else to clean up the mess you made. Don't do osteopathic manipulations on the C spine either.

**disclaimer: I do work with a select group of well meaning PCP's who inherited opioid patients from other prescribers and help them wean patients safely and appropriately. Any patient they refer knows exactly what to expect and all are willing participants in the taper. If they try to dump on me then I close the door permanently**

 

[244913]

We offered him PT, facet injections, and told him to engage in yoga. Also that he should return to his primary care and be weaned slowly off opioids over 4 months. He was not amused.

I can picture how that interaction went..one patient like that can ruin a morning even if the other 15 are great

 

[painfree23]

We offered him PT, facet injections, and told him to engage in yoga. Also that he should return to his primary care and be weaned slowly off opioids over 4 months. He was not amused.

What do u do when the “injections make him worse”

 

[John1513]

@drusso

Thank you! Informative and practical! I will share this with others. These type of patients are inherited. 12 tramadol once every 5 years does not make an addict.

However, the patient on OxyContin and Oxycodone are the quickest and most expiditious with filing a negative customer complaint when not getting their way.

I’ll definitely be looking into, and utilizing Opioid Use Disorder and Fibromyalgia more often.

Graci!

 

[Blitz2006]

We offered him PT, facet injections, and told him to engage in yoga. Also that he should return to his primary care and be weaned slowly off opioids over 4 months. He was not amused.

So for my own learning, it is not considered "abandonment" if a pain physician does not agree to continue prescribing opioids as an adjunct to your aforementioned treatments?

 

[SommeRiver]

So for my own learning, it is not considered "abandonment" if a pain physician does not agree to continue prescribing opioids as an adjunct to your aforementioned treatments?

Of course not.

Just bc a pt is on chronic opiates yesterday means nothing about how I would treat them today.

 

[RM38]

So for my own learning, it is not considered "abandonment" if a pain physician does not agree to continue prescribing opioids as an adjunct to your aforementioned treatments?

Yes it is not abandonment on our part and we are not held to the prescribing standards of previous physician just because they don't want to prescribe anymore. If I don't agree that the previous treatment plan is appropriate and the patient does not want any part of what I have to offer then they can go back to the prescribing doc and have them continue their previous treatment plan. If they go back and that doc doesn't want to do it, it is their problem, not mine. Here in FL with the new laws it seems as though all non-pain docs want to dump their opioid Rx on us (even though they absolutely can still Rx) and I would say at least 50-75% of those people have no business being on COT and I tell the patients that on the first visit in a very straightforward manner to avoid confusion. Many never come back, but some do. In some very egregious cases I will be extra nice and call the referral source to discuss what is more than likely going to happen so they aren't just reading it in a note or hearing about how big of an piece of crap I am over the phone. Also my office staff instructs all new patient referrals that if they are on opioids, that medications are absolutely not guaranteed to be apart of their treatment plan and that I may deny taking over the Rx or reduce it dramatically. They are also informed that they are expected to follow treatment plans that I feel are appropriate for them. That eliminates a lot of the people that just want their pills and don't want to do PT, HEP, injections, psych, imaging, etc.

 

[NJPAIN]

I may have seen my last pain patient ever yesterday. A guy who is taking 100mcg/hr fentanyl plus oxycodone 80mg a day for low back pain. The family doc is nervous about prescribing that much with new state opioid prescribing laws beginning today. Never had PT, never had injections or any other significant therapy- just drugs, drugs, drugs for years. We accepted the patient into the practice I was covering, but not for opioid prescribing. It is the inappropriate prescribing of opioids that has made pain medicine a cesspool and a dumping ground. This is the reason why pain physicians do not accept the mistreated patients subjected to the substandard care of amateurs who have not kept up with current medical literature about opioids. Pain clinics are expected by other physicians to take over and continue outrageous prescribing patterns, or to become detox clinics. This is not why pain physicians went into pain medicine- to deal without other doctor's screwups.

Well said. Inappropriate opioid prescribing has virtually ruined this field.


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[Ronin1]

I find that prescreening is very effective. I simply do not take any new patients looking for medication management. I don’t want to waste my time or the patients time/money on conversations that is not going to lead to engagement.

 

[NJPAIN]

Yes it is not abandonment on our part and we are not held to the prescribing standards of previous physician just because they don't want to prescribe anymore. If I don't agree that the previous treatment plan is appropriate and the patient does not want any part of what I have to offer then they can go back to the prescribing doc and have them continue their previous treatment plan. If they go back and that doc doesn't want to do it, it is their problem, not mine. Here in FL with the new laws it seems as though all non-pain docs want to dump their opioid Rx on us (even though they absolutely can still Rx) and I would say at least 50-75% of those people have no business being on COT and I tell the patients that on the first visit in a very straightforward manner to avoid confusion. Many never come back, but some do. In some very egregious cases I will be extra nice and call the referral source to discuss what is more than likely going to happen so they aren't just reading it in a note or hearing about how big of an piece of crap I am over the phone. Also my office staff instructs all new patient referrals that if they are on opioids, that medications are absolutely not guaranteed to be apart of their treatment plan and that I may deny taking over the Rx or reduce it dramatically. They are also informed that they are expected to follow treatment plans that I feel are appropriate for them. That eliminates a lot of the people that just want their pills and don't want to do PT, HEP, injections, psych, imaging, etc.

Same thing happened here in N.J. No one will prescribe. My wife’s aunt had an outpatient TKA last week. Performed by a joint replacement specialist. Discharged from hospital with Tramadol and Celebrex. Lives alone, can’t even make it to the bathroom and certainly can’t do PT. My bet is that they will refer her to pain management stating that she has failed their usual protocol. Then the pain doc will write the CII.


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[RM38]

Same thing happened here in N.J. No one will prescribe. My wife’s aunt had an outpatient TKA last week. Performed by a joint replacement specialist. Discharged from hospital with Tramadol and Celebrex. Lives alone, can’t even make it to the bathroom and certainly can’t do PT. My bet is that they will refer her to pain management stating that she has failed their usual protocol. Then the pain doc will write the CII.


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Most annoying thing is that the law here mostly just applies to acute pain, but pcps have all interpreted the law as they can only write for up to 7 days of meds and that is it. The law does not limit them from managing chronic pain, but does put certain requirements on the doc in that they must check the Rx database, must put "non acute pain" on the Rx itself along with several other standards that any doctor should really be doing for patients with chronic pain anyways. There is a pre-existing law that says that anybody prescribing controlled substances to >50% of their patients must register as a pain clinic with some exceptions for pain physicians. Also insurances have gone crazy with the prior auths. Hell the law doesn't even require a UDS. PCPs just don't want to do that, so they dumping it all. Funniest thing is that they are also prescribing benzos, which have some the same requirements for monitoring that are there for opiates, but they are planning on continuing those. So obviously they have not read the law and don't know that benzo+opiate=bad idea. When it comes to ortho I have started to see some pre-OR consults for post op pain management, which you might start to see up there as well. I had one consult like 4 days post op for an arthroscopic shoulder that I had on my schedule until he admitted to my staff that his pain was not controlled because he fell on his shoulder 2 days after his operation and he was too embarrassed to tell his surgeon. I refused consult and told him to go and tell his surgeon the truth.

 

[Pacman27]

We offered him PT, facet injections, and told him to engage in yoga. Also that he should return to his primary care and be weaned slowly off opioids over 4 months. He was not amused.

I would have done all of the above but refused procedures on him until he was weaned off completely or to a adequate dose.

" Pain medicine" is a one year fellowship and with multiple different interpretations. Fellowships vary as well. All that is okay IMO because it is a broad field. In my practice we focus on spine and joint related issues with minimal to no opioids. That is my choice and has worked out great for me.

I have referred patients myself to "pain management" when the patient only wanted opioids. There are other docs in my community who are happy to do this and they can treat these patients better then I can.

 

[Ducttape]

um....

Algos, what do you mean by “I may have seen my last pain patient ever”?
Going to retire for good?

 

[John1513]

Thank you for all of your perspectives, they are very helpful.

1) Would you mind if a Family Doc sent you an “evaluation only” consult to advise on taper down plan and/or approve of the meds that a chronic pain pt is currently on?

2) I send patients all the time for Interventional Pain... nerve blocks, Epidurals etc. would insurance know what to do if I put a consult in as “Chronic Pain medicine evaluation and treat?” Do pain docs even distinguish themselves to insurance as Interventional Vs Chronic? Example I’m thinking of is Ortho: ortho hand surgeon isn’t sent SLAP tears or knees .. somehow ortho can distinguish themselves to insurance?

 

[lobelsteve]

Thank you for all of your perspectives, they are very helpful.

1) Would you mind if a Family Doc sent you an “evaluation only” consult to advise on taper down plan and/or approve of the meds that a chronic pain pt is currently on?

2) I send patients all the time for Interventional Pain... nerve blocks, Epidurals etc. would insurance know what to do if I put a consult in as “Chronic Pain medicine evaluation and treat?” Do pain docs even distinguish themselves to insurance as Interventional Vs Chronic? Example I’m thinking of is Ortho: ortho hand surgeon isn’t sent SLAP tears or knees .. somehow ortho can distinguish themselves to insurance?

If you were new to me I would appreciate a phone call and I would be happy to take you out to dinner and explain my practice and how I take care of patients. The easiest way to get started is to have that conversation to find out if your doctor is comprehensive, a pill Pusher, or a needle jockey.

 

[drrosenrosen]

Thank you for all of your perspectives, they are very helpful.

1) Would you mind if a Family Doc sent you an “evaluation only” consult to advise on taper down plan and/or approve of the meds that a chronic pain pt is currently on?

2) I send patients all the time for Interventional Pain... nerve blocks, Epidurals etc. would insurance know what to do if I put a consult in as “Chronic Pain medicine evaluation and treat?” Do pain docs even distinguish themselves to insurance as Interventional Vs Chronic? Example I’m thinking of is Ortho: ortho hand surgeon isn’t sent SLAP tears or knees .. somehow ortho can distinguish themselves to insurance?

I for one, am happy to see exactly these type of med evaluation patients. If you're letting me know up front that you are asking for an expert opinion on your continued management of this patient, then I'm going to be happy to give you my expert opinion. If you're trying to dump patients you don't want to deal with anymore, I'm not your guy. I think many people here would say the same thing.

There is not any way of distinguishing practices between interventional and not. Any fellowship trained pain management physician will have been trained primarily in interventional management, but with plenty of exposure to med management as well. Many of us try not to do much in the way of med management, so I'd say the best way to know is to get to know your local pain docs and see who is comfortable seeing what patients.

 

[drusso]

Thank you for all of your perspectives, they are very helpful.

1) Would you mind if a Family Doc sent you an “evaluation only” consult to advise on taper down plan and/or approve of the meds that a chronic pain pt is currently on?

2) I send patients all the time for Interventional Pain... nerve blocks, Epidurals etc. would insurance know what to do if I put a consult in as “Chronic Pain medicine evaluation and treat?” Do pain docs even distinguish themselves to insurance as Interventional Vs Chronic? Example I’m thinking of is Ortho: ortho hand surgeon isn’t sent SLAP tears or knees .. somehow ortho can distinguish themselves to insurance?

A phone call or a heads up certainly helps. Our group has a referral form that you can use or can be converted into an EHR friendly work-ticket that specifies what kind of service you're seeking: Eval & Treat, steroid injection, DX ultrasound, SCS, spasticity management, regenerative therapy injection, EMG/NCS, chronic pain education program, buprenorphine treatment program, industrial medicine/worker's comp management, etc.

You could also actually stop by and visit the clinic. This allows you to actually shake hands with the various providers and look at them eye-to-eye, see the procedure rooms, meet the referral coordinator, and get a sense for what kind of patients can be helped.

 

[hyperalgesia]

Thank you for all of your perspectives, they are very helpful.

1) Would you mind if a Family Doc sent you an “evaluation only” consult to advise on taper down plan and/or approve of the meds that a chronic pain pt is currently on?

2) I send patients all the time for Interventional Pain... nerve blocks, Epidurals etc. would insurance know what to do if I put a consult in as “Chronic Pain medicine evaluation and treat?” Do pain docs even distinguish themselves to insurance as Interventional Vs Chronic? Example I’m thinking of is Ortho: ortho hand surgeon isn’t sent SLAP tears or knees .. somehow ortho can distinguish themselves to insurance?

1. I have no problem if the consult specifically asks for this. Sometimes it just helps to have a pain doc educate and reinforce the plan. It's not always a one-person job!

2. Insurance won't know the difference.

 

[Ferrismonk]

I appreciate knowing exactly what the referring provider is looking for. Sometimes they just want the patient to "see pain management" so they can document that there's nothing else that can help. Other times they just want a certain procedure. Sometimes they want me to take over everything and relieve the PCP of their headache. The more specific the referral, that happier we all are.

What I hate is when the patient arrives, but has no idea why they're a the office. PCP note doesn't say why, and I'm unsure if PCP is trying to get me to take over narcotics or not.