Pain management for the primary care physician

[Bacchus]

Greetings!

I couldn't think of a better place to ask this so here it goes. I was hoping that as pain medicine certified physicians you would be able to point me in the right direction for resources. Is there a consensus among the pain medicine community what good resources are available for self study or have teaching such as CME done in regards to managing pain in the primary care setting?

I'm at a rural office and have several patients that are on chronic opioids, some of them for a very long time which I know I won't be able to wean off of the opioid medications and thUs are getting them stabilized on long acting medications without need for IR preps.

PM in our area is almost exclusively intervention only.

I feel fairly comfortable managing opioids and try not to start opioids and only continue those where absolutely necessary but I can't as an employed physician say no to patients establishing at our office and then feel guilty if they don't feel well from their pain.

It's rather complex. Any good resources so I can even comanage with PM who will do interventions?

I'm beyond greatful I did a 6 week palliative rotation in residency to be more comfortable.

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[oreosandsake]

those are great questions regarding a very complicated subject. there are some great courses out there that encompass a lot of the topics you touch upon. this may be a great option for you http://www.asipp.org/documents/0717-CSM-brochure.pdf

 

[SeniorWrangler]

The CORE-REMS program is pretty good and directed at primary care who want to treat pain without contributing to addiction:
Opioid Education

 

[Timeoutofmind]

Wean everyone

Opioids dont help in chronic pain, the data is overwhelming in the literature. In fact they make it worse and have tons of serious side effects

Dont try and dump them on other docs

Do it yourself

Non-optional for the patients. Dont let them go in circles, explain yourself briefly and reiterate once or twice and then walk out if they wont stop. Those conversations should not take more than 5-10min tops, ever...

10% a week is the standard recommendation.

Its not complicated at all.

If they dont like it they can go elsewhere

You will be doing an immeasurable good to those patients and your community if you have the guts

 

[lobelsteve]

Wean everyone

Opioids dont help in chronic pain, the data is overwhelming in the literature. In fact they make it worse and have tons of serious side effects

Dont try and dump them on other docs

Do it yourself

Non-optional for the patients. Dont let them go in circles, explain yourself briefly and reiterate once or twice and then walk out if they wont stop. Those conversations should not take more than 5-10min tops, ever...

10% a week is the standard recommendation.

Its not complicated at all.

If they dont like it they can go elsewhere

You will be doing an immeasurable good to those patients and your community if you have the guts

Sounds like an alarmist an uneducated viewpoint. The only thing that helps is my needle. Next.

 

[Timeoutofmind]

Sounds like an alarmist an uneducated viewpoint. The only thing that helps is my needle. Next.

You know nothing about my practice.

I am more multimodal by far than most on this board.

Opioids dont work bro, nothing alarmist about it

Do whats right people

 

[SeniorWrangler]

Maybe not the most helpful advice to a primary care doc

Sounds like an alarmist an uneducated viewpoint. The only thing that helps is my needle. Next.

Needles don't heal people. Steve Lobel heals people.

 

[Timeoutofmind]

Maybe not the most helpful advice to a primary care doc

It is very helpful advice

A number of clinic/PCP groups in my area just set an arbitrary date in the future and became no opioids from there forward. If people dont set up another prescriber with all that notice, they are out of luck.

 

[gdub25]

Opioids don't help pain or function. There's a reason all the pain management docs in you're area don't prescribe.

 

[Ducttape]

Needles don't heal people. Steve Lobel heals people.

if Chuck Norris was a pain doc, he'd be Steve Lobel...

 

[bedrock]

We are pain specialists.

These recent comments on opioids are reminding me of politics. The 15% of the country that are hardcore ultra-leftist that want a total socialism and a complete welfare state and corresponding 70% tax rate are all complete *****s. The 15% that are hardcore ultra rightwingers that want absolutely no social safety nets, and for kids to being able to walk around freely carrying automatic weapons, are all complete *****s. There are nuances in the middle ground that reasonable moderate Republicans and reasonable moderate Democrats can and should debate.

Similarly as pain specialists in our area of expertise, an absolute position of no opioids for anyone is ridiculous, just like it is ridiculous to give high dose of opioids to all our patients. We've all been burned by some crazy patients in our training or afterwards, but that doesn't mean we should turn our backs on our patients. There are nuances in the middle ground that we have to consider if we are caring for people as physician specialists.
Think of the grandmother with multiple significant pain generators for whom Norco 5 BID allows a much more full and functional life. What would you do for your grandmother/mother?
Or the father of three with several real pain generators, who has complied but failed all your multimodal and procedural treatments and needs to continue working full-time at his physical job to support his family, which he can do with his Norco 7.5 TID, etc, etc.

Absolutely ridiculous to say no opioids for anyone. Lots of people currently on opioids should be taken off them, but not everyone. There is a middle ground about which we can have a healthy and reasonable debate. But absolute polarized positions are the clearest indicator of a closed or simply feeble mind.

 

[drpainfree]

We are pain specialists.

These recent comments on opioids are reminding me of politics. The 15% of the country that are hardcore ultra-leftist that want a total socialism and a complete welfare state and corresponding 70% tax rate are all complete *****s. The 15% that are hardcore ultra rightwingers that want absolutely no social safety nets, and for kids to being able to walk around freely carrying automatic weapons, are all complete *****s. There are nuances in the middle ground that reasonable moderate Republicans and reasonable moderate Democrats can and should debate.

Similarly as pain specialists in our area of expertise, an absolute position of no opioids for anyone is ridiculous, just like it is ridiculous to give high dose of opioids to all our patients. We've all been burned by some crazy patients in our training or afterwards, but that doesn't mean we should turn our backs on our patients. There are nuances in the middle ground that we have to consider if we are caring for people as physician specialists.
Think of the grandmother with multiple significant pain generators for whom Norco 5 BID allows a much more full and functional life. What would you do for your grandmother/mother?
Or the father of three with several real pain generators, who has complied but failed all your multimodal and procedural treatments and needs to continue working full-time at his physical job to support his family, which he can do with his Norco 7.5 BID, etc, etc.

Absolutely ridiculous to say no opioids for anyone. Lots of people currently on opioids should be taken off them, but not everyone. There is a middle ground about which we can have a healthy and reasonable debate. But absolute polarized positions are the clearest indicator of a closed or simply feeble mind.

well-said

 

[lonelobo]

If I didn't prescribe Narcotics to my patients, then I wouldn't be able to buy them back and sell them at da Club to pay for my three Vacation homes in the Caribbean .....duh

 

[Disciple]

Greetings!

I couldn't think of a better place to ask this so here it goes. I was hoping that as pain medicine certified physicians you would be able to point me in the right direction for resources. Is there a consensus among the pain medicine community what good resources are available for self study or have teaching such as CME done in regards to managing pain in the primary care setting?

I'm at a rural office and have several patients that are on chronic opioids, some of them for a very long time which I know I won't be able to wean off of the opioid medications and thUs are getting them stabilized on long acting medications without need for IR preps.

PM in our area is almost exclusively intervention only.

I feel fairly comfortable managing opioids and try not to start opioids and only continue those where absolutely necessary but I can't as an employed physician say no to patients establishing at our office and then feel guilty if they don't feel well from their pain.

It's rather complex. Any good resources so I can even comanage with PM who will do interventions?

I'm beyond greatful I did a 6 week palliative rotation in residency to be more comfortable.

Here's a pretty good overview for primary care.

AAPM Education Center

 

[Bacchus]

I'm glad I got some serious replies. A colleague and me are trying to establish some type of helpful pain protocol for the office and train our more liberally prescribing physicians. We have the "absolutely nots" and the "take this like you'd take an MVI in the office." My chronic opioid patients of whom are on significant OMEs are open to weaning and alternatives but my two highest OME patients have tried it all and I see no reason to have them in chronic, unbearable pain when they're taking what they're on responsibly and being productive society members.

Sorry to stir up the hive.