Pain management

[mjl1717]

This is a relatively new field... At one time the thought was do not give schedule II's, it will cause addiction.. Currently the thought is treat someone with chronic intractable pain. I recently started working part ime with a practoner who does this.. Does anyone have any insight into this field?...

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[alfonzarel]

yeah, they make bank

 

[78222]

This is a relatively new field... At one time the thought was do not give schedule II's, it will cause addiction.. Currently the thought is treat someone with chronic intractable pain. I recently started working part ime with a practoner who does this.. Does anyone have any insight into this field?...

wait, what's your question?

I wouldn't go into a pain managment field myself. Not so much because of the drug seekers (I'd rather give drugs to a malingerer than deny someone who actually needs them), but because of the DEA. The DEA has repeatedly targeted doctors who prescribe pain meds and treated them like they are crack dealers.
http://www.villagevoice.com/2003-11-04/news/the-dea-s-war-on-pain-doctors/
http://www.washingtonpost.com/wp-dyn/articles/A20537-2004Nov29.html

 

[mjl1717]

yeah, they make bank

Yes, in the back of my mind I say that to myself... (think they do)
Not without a real cost--{no easy way}
Anyone else wanna chime in..

 

[mjl1717]

wait, what's your question?

I wouldn't go into a pain managment field myself. Not so much because of the drug seekers (I'd rather give drugs to a malingerer than deny someone who actually needs them), but because of the DEA. The DEA has repeatedly targeted doctors who prescribe pain meds and treated them like they are crack dealers.
http://www.villagevoice.com/2003-11-04/news/the-dea-s-war-on-pain-doctors/
http://www.washingtonpost.com/wp-dyn/articles/A20537-2004Nov29.html

I looking for someone who REALLY knows this burgeoning field or who has had ample exposure in pain management... I simply asking the pros and cons of this field..

 

[mjl1717]

wait, what's your question?

I wouldn't go into a pain managment field myself. Not so much because of the drug seekers (I'd rather give drugs to a malingerer than deny someone who actually needs them), but because of the DEA. The DEA has repeatedly targeted doctors who prescribe pain meds and treated them like they are crack dealers.
http://www.villagevoice.com/2003-11-04/news/the-dea-s-war-on-pain-doctors/
http://www.washingtonpost.com/wp-dyn/articles/A20537-2004Nov29.html

Buddy thank you for the info: I noticed the DEA at that time did NOT have steadfast policy concerning this...Also be aware those articles are 4 and 5 years old (things may have changed)..Thank you for the insight!

 

[Mr hawkings]

Buddy thank you for the info: I noticed the DEA at that time did NOT have steadfast policy concerning this...Also be aware those articles are 4 and 5 years old (things may have changed)..Thank you for the insight!

I dont know about other specialties but all anesthesiologists are assigned a DEA ID number after they pass they state licensure exams. This number is on the prescriptions. I assume that they are tracked in some way by the DEA accorinding to what they are prescribing.

 

[mjl1717]

I dont know about other specialties but all anesthesiologists are assigned a DEA ID number after they pass they state licensure exams. This number is on the prescriptions. I assume that they are tracked in some way by the DEA accorinding to what they are prescribing.

Yes, DEA, the state, and even pharmacies to an extent monitor BIG TIME!!
I think that one classical conflict is:

Deciding who is in chronic pain (eg.motorcycle accident, laminectomy fibromyalgia) versing mere (eg.manipulating, unscruplous) drug seekers..

 

[PMR 4 MSK]

I looking for someone who REALLY knows this burgeoning field or who has had ample exposure in pain management... I simply asking the pros and cons of this field..

pros - interesting work, challenging, rapidly changing (usually for the better), opportunity to radically change someone's life (again, hopefully for the better...), procedures pay more than coginitive medicine, except for Medicare/caid

Cons - drug addicts seek you out, but most experienced pain docs know how to spot them and get rid of them, pts often demanding and manipulative, personality disorders and other psych disorders common.

The risk of DEA investigation is very low. Those physicians "targeted" are usually hanging themselves and giving the DEA all the ammo they need - poor documentation, unimodal therapy (opioids), high % self-pay, trading Rx for sex or other drugs, etc.

 

[mjl1717]

pros - interesting work, challenging, rapidly changing (usually for the better), opportunity to radically change someone's life (again, hopefully for the better...), procedures pay more than coginitive medicine, except for Medicare/caid

Cons - drug addicts seek you out, but most experienced pain docs know how to spot them and get rid of them, pts often demanding and manipulative, personality disorders and other psych disorders common.

The risk of DEA investigation is very low. Those physicians "targeted" are usually hanging themselves and giving the DEA all the ammo they need - poor documentation, unimodal therapy (opioids), high % self-pay, trading Rx for sex or other drugs, etc.

Thank you.. Question, if a patient has a positive urine screen in this arena what should happen and what usually happens?

 

[Arch Guillotti]

I dont know about other specialties but all anesthesiologists are assigned a DEA ID number after they pass they state licensure exams. This number is on the prescriptions. I assume that they are tracked in some way by the DEA accorinding to what they are prescribing.

What state licensure exams do you mean?

In general, licensure is gained via passing all three national exams (COMLEX or USMLE), for the most part completing at least a year of GME, then applying for an unrestricted license through the state medical board. The you can appy for your own DEA # through the feds.

 

[Aether2000]

This entire thread is confusing to me...pain management (practiced by chiropractors, nurses, acupuncturists, Reiki energy field believers, rolfers, antiageing medicine doctors, auriculotherapists, colonic cleansers, and voodoo practitioners) stands in contradistinction to pain medicine (cancer pain, non-malignant care, interventional pain medicine, comprehensive pain therapy, etc practiced by pain physicians). The issue surrounding DEA incursion into physician's practices are largely moot. The DEA rarely targets physicians at all and those that it does usually have a long history of shady activities that most physicians would find unsavory. The hysterical hype espoused by Dr Heit in 2004 who stated up to 90% of physicians and patients receiving opiates could be targeted was nonsense then and has been disproven. Didn't happen, couldn't have happened given the limitations of the DEA investigative unit size. Also remember the DEA is not capable of policing substance abuse...it is outside the parameters of the drug enforcement act of 1971. However the DEA is interested (as should legitimate physicians) in eradicating drug diversion. Physicians receiving kickbacks for selling opiates (makes in-house pharmacies in physician offices selling opiates a potentially dangerous proposition.), those trading sex for opiates, self prescribing or for family members, those with sloppy records that do not follow the FSMB guidelines, and doctors that knowingly prescribe to those that are diverting prescribed opiates are in danger of DEA action against them. But most legitimate physicians would never dream of engaging in these illegal activities.

 

[PMR 4 MSK]

Thank you.. Question, if a patient has a positive urine screen in this arena what should happen and what usually happens?

By "positive" you mean something in there that shouldn't be when they are on opioids, I assume?

What should happen is an investigation by the doctor as to why the screen is other than expected - consideration of metabolites of the prescribed medication (e.g. hydrocodone to hydromorphone, codeine to morphine), over use or lack of use of the prescribed medication, other sources of medications (friends, family, dealers), adulterants, false postives and negatives.

No urine drug screen result, like any test, stands alone - it must be considered in the context of the patient.

What usually happens? Trigger-happy docs fire the patient and turn a potential to treat a co-morbid disorder like addiction into a punishment and pour gas on the fire.

 

[mjl1717]

By "positive" you mean something in there that shouldn't be when they are on opioids, I assume?

What should happen is an investigation by the doctor as to why the screen is other than expected - consideration of metabolites of the prescribed medication (e.g. hydrocodone to hydromorphone, codeine to morphine), over use or lack of use of the prescribed medication, other sources of medications (friends, family, dealers), adulterants, false postives and negatives.

No urine drug screen result, like any test, stands alone - it must be considered in the context of the patient.

What usually happens? Trigger-happy docs fire the patient and turn a potential to treat a co-morbid disorder like addiction into a punishment and pour gas on the fire.

Im saying that THC, cocaine or methamphetamine showed up in the urine.. And the patient usually denies it..

 

[PMR 4 MSK]

Im saying that THC, cocaine or methamphetamine showed up in the urine.. And the patient usually denies it..

I give the choice of weaning off the opioids or 30 days and find a new doc. They have already signed an agreement, stating among other things, that they will not use these drugs while receiving opioids from me. By using those, they have lied to me, as well as violating the agreement. I used to give second chances, but then they always eventually test positive again, so I gave up second chances.

If I use a dipstick and they contest the results, I send for GC/MS (Gas Chromatography / Mass Spectometry). If positive on GC/MS, I stand by the test. Dipsticks have many more false positives than GC/MS.

 

[mjl1717]

I give the choice of weaning off the opioids or 30 days and find a new doc. They have already signed an agreement, stating among other things, that they will not use these drugs while receiving opioids from me. By using those, they have lied to me, as well as violating the agreement. I used to give second chances, but then they always eventually test positive again, so I gave up second chances.

If I use a dipstick and they contest the results, I send for GC/MS (Gas Chromatography / Mass Spectometry). If positive on GC/MS, I stand by the test. Dipsticks have many more false positives than GC/MS.

Thank you.. this is where the patient /doc relationship gets very touchy..And I think the dialogue has to be somewhat firm..

 

[GuP]

Can the seniors chime in on what your regular day is like? How is a typical week divided between clinic and procedures? Is private practive and hanging up your own shingle first year out of fellowship the norm OR can you work for a hospital?

 

[PMR 4 MSK]

I do 1/3 of my time in clinic, 1/3 doing procedures, 1/3 EMG. In clinic I schedule f/u pts for 15 min and new for 30 min. Procedures I scheudle for 30 min each, EMG's 1 hour.

Straight out of training you can do anything - solo, group, be owned by a hospital. IMHO, it's better to get in with people who know how to run a business (groups) at the start, unless you are already good at business. In medicine, odds of that are low. I thought I was, went solo from the start, and ended up taking it in the shorts. Also - see how many posts there are around here about basic business - recent grads know nothing about business, in general.

Stay away from hospital-employment if you can - they see pain docs as $ machines for them and expect high-resource utilization, and they will screw you as often as they can. If you just think of hospital administrators as car salesman, you'll know all you need to know about them.

 

[Mister Mxyzptlk]

1/3 clinic
1/3 procedures
1/3 wasting time on the Internet

 

[ghost dog]

Hi ,

I find an on-site urine drug screen to be an invaluable tool for providing a glimpse into my chronic pain patient's "pharmacological lifestyles". I obtain a test result within 5 minutes using this kit.

I have yet to see a false positive for cocaine with this urine drug screen kit , although opioids and benzos are less reliable for some reason (I always send them to the lab for confirmation).

For the doctor starting out in pain medicine, here are a few of the usual (and some unusual , creative) excuses I hear about how or why a cocaine urine drug screen was (mysteriously) positive:

1. Someone "put it" in his or her drink.

2. Someone put cocaine in their marijuana cigarette without their knowledge (?!).

3. One of his or her friends was smoking crack, and they must have inhaled the second hand smoke.

4. This test result is impossible. "There's just no way doc!"

All of the above are obviously complete nonsense.

I find if I look them in the eye and confront them firmly (but not rudely), they ALMOST always admit to using cocaine in the end. Over the years, this has worked every time with only one notable exception.

Ghost dog.

 

[PMR 4 MSK]

Hi ,

I find an on-site urine drug screen to be an invaluable tool for providing a glimpse into my chronic pain patient's "pharmacological lifestyles". I obtain a test result within 5 minutes using this kit.

I have yet to see a false positive for cocaine with this urine drug screen kit , although opioids and benzos are less reliable for some reason (I always send them to the lab for confirmation).

For the doctor starting out in pain medicine, here are a few of the usual (and some unusual , creative) excuses I hear about how or why a cocaine urine drug screen was (mysteriously) positive:

1. Someone "put it" in his or her drink.

2. Someone put cocaine in their marijuana cigarette without their knowledge (?!).

3. One of his or her friends was smoking crack, and they must have inhaled the second hand smoke.

4. This test result is impossible. "There's just no way doc!"

All of the above are obviously complete nonsense.

I find if I look them in the eye and confront them firmly (but not rudely), they ALMOST always admit to using cocaine in the end. Over the years, this has worked every time with only one notable exception.

Ghost dog.

In a dipstick I used to use, tagamet caused false-positives frequently.

I just love that people think that I'm going to buy their excuse that someone else has nothing better to do with $100/gm coke than to put it in their drink, food, etc on the off-chance I'm going to UDS them within a couple days. Every excuse like that gets the same response from me - "There's only one way the cocaine/MJ got into your urine - you put it in your body in some form, and you knew what you were doing. Don't try to test me to see if I'm stupid." That last line gets 'em almost every time.

 

[Aether2000]

Our lab has been instructed to GC/MS test all opiates automatically and for positive results in any other class. This gives virtually 100% accuracy and is not disputable in my book.
One of the more bizarre incidences was when a patient failed a UDS for marijuana and told us her family held her down and forced a mask over her face from a water pipe with marijuana vapor entering her body...
Because it was so original, we gave her a warning only, but then 3 months later she was found to have unprescribed opiates in her system. We are now weaning her from all opiates...probably should have started that several months ago...

 

[dc2md]

Because it was so original, we gave her a warning only, but then 3 months later she was found to have unprescribed opiates in her system. We are now weaning her from all opiates...probably should have started that several months ago...

that IS good!!! but advertising points for originality on a public forum. yikes! now you're gonna have ever Hoosier drug seeker in the state getting creative.

anyone else have any doozies (sp?) off the top of their head??

 

[ghost dog]

that IS good!!! but advertising points for originality on a public forum. yikes! now you're gonna have ever Hoosier drug seeker in the state getting creative.

anyone else have any doozies (sp?) off the top of their head??

I once had a patient test positive for demerol (on a lab opioid breakdown) .

I discussed this result with her, and she professed to have no knowledge of the demerol, being on the fentanyl patch (surprise, surprise). She became quite concerned with this positive test and then questioned whether or not someone may be injecting her at night with this substance.

This was such a bizarre suspicion, (and she was such a convincing liar ) that I let this positive drug screen "slide" until it happened again. Then I finally wised up. I should note that this was at the beginning of my career as a chronic pain doc, and I was considerably more naive back then.

GD

 

[dc2md]

i'm sure i'll be suckered into letting some positive drug screens slide with some good acting too. those types of people are just such good liars.

LOVE that puzzlement though. is she so F'd up while she sleeps that she thinks someone could inject her and she not remember?? LOL. wait, maybe the pharm company screwed up and put a little demerol in the patch on accident too. or you know what, she probably got it into her when she sat on that toilet in the truckstop bathroom. yep, that was probably it. and the nurse who took her urine doesn't like her and probably spiked the sample. so many possibilities.

 

[ghost dog]

pros - interesting work, challenging, rapidly changing (usually for the better), opportunity to radically change someone's life (again, hopefully for the better...), procedures pay more than coginitive medicine, except for Medicare/caid

Cons - drug addicts seek you out, but most experienced pain docs know how to spot them and get rid of them, pts often demanding and manipulative, personality disorders and other psych disorders common.

The risk of DEA investigation is very low. Those physicians "targeted" are usually hanging themselves and giving the DEA all the ammo they need - poor documentation, unimodal therapy (opioids), high % self-pay, trading Rx for sex or other drugs, etc.

Hi All,

Practicing in Canada, I feel like I'm in "the land of milk and honey" when I hear some of the horror stories about the DEA and opioid prescribing.

When a Canadian physician makes a bad opioid prescribing call with a patient (or a number of patients), the worst thing that happens here is the college revokes their opioid prescribing license (unless its some kind of malicious practice, like sex for drugs , etc). In the U.S. , the doc could face jail time. Can't they?

I mean , we've all been fooled by convincing liars. Is this situation really as bad as the media makes it out to be in the States ?

 

[Aether2000]

Jail time in the US is not for those that have substance abusers in their practice but for those that fall into one of two categories:
1. kickbacks for drugs or other involvement with drug diversion
2. eggregious overprescribing well outside the standard of care that results in multiple patient deaths....this has only happened a couple of times in the US

 

[spinepain]

I’ve had two good ones recently.

1. 35 yo man with UDS positive for cocaine. He said he wasn’t using. He must be positive via skin absorption due to handling so much of it when cutting and bagging.
2. 54 you woman positive for amphetamine. She wasn’t using. She was positive because “I have to bite my grandson’s ADD medicine in half every morning”

 

[Mister Mxyzptlk]

I had one last week positive for THC. I told him I was sending it for GCMS and he mentioned that he thought it might have been "laced" with something. In these circumstances where the dipstick could be false positive I give a 7 day supply of meds pending the formal assay. Came back positive for cocaine. When he called my nurse about a refill she told him about the cocaine. He denied using cocaine and swore that it must have been in the joint he smoked.

I told her to tell him that I only LOOK stupid. Besides "Unbeknownst to me, there was a second illegitimate drug mixed into the first illegitimate drug" is not really a good excuse.

I had a new patient yesterday who ratted out one of my other patients. I never would have suspected it, but when we called some pharmacies, sho' nuff she was doctor-shopping.

 

[Tenesma]

i love how the excuses evolve

1) inform patient positive THC in urine

2) she looks dumbfounded and asks: "what is marijuana?"

3) I explain to her what it is - she looks SHOCKED, and states "how could i test positive for something i never heard of before"

4) then i point out that it got into her body somehow

5) she feigns SURPRISE

6) she then says that her (racist-comment) neighbors smoke something weird-smelling - and maybe it is second hand smoke

7) i tell her that second-hand smoke doesn't show up in UDS/GCMS

8) she then smacks her head, and says that her boyfriend smokes a lot of cigarettes and maybe SOMEBODY put something into his Camel Lights

9) I shake my head... and again explain that is not how it works

10) THEN she says that she is on prilosec and that she heard that that can cause false-positive results for certain things

11) I ask her how she knows that - she says she heard it at the laundromat that same morning...

12) I tell her that the lab I use, does not get false-positives with prilosec

13) she then tells me that her boyfriend sometimes MAKES her smoke his cigarettes to soothe her menstrual cramps....

14) her boyfriend is out in the waiting room - i wave him into the room - he comes in - I ask him (before she gets a chance to say anything) "what do you give her for her menstrual cramps?".... His answer --- "nothing".

15) she then explains to me it is her ex-boyfriend that would force her to smoke cigarettes...

16) i then ask her how long ago that relationship ended - she says 4 years ago...

17) i explain that this shows use in the last 30 days...

18) the boyfriend looks at her and then looks at me and says: "she ain't smoked a joint in at least 2 months" and then he asks me "Doc, how long before cocaine gets out of your system..."

19) she leaves the office just as I am about to explain to her that she is full of crap

20 minutes spent for a wonderful $19 (medicaid HMO plan in my state)....

I get a phone call from PCP 3 days later, asking why I was so mean to her patient and that Marijuana is not a bad drug... I explained to her that I don't have a problem with Marijuana per se... I have a problem with using controlled substances in a patient that can't be trusted and who is a liar...

Two months later, same PCP calls me back and apologizes, and explains that the patient stole her prescription pads (!)... hmmm....

 

[dc2md]

tenesma, that's just perfect!! great story. you had to go through all of that for $19?? wow!! i wish you could've recorded that.

 

[Mister Mxyzptlk]

Never heard of MJ (what planet does she live on?) but knows that prilosec can cause false (+) THC on UDT? Most docs don't know that.

 

[Tenesma]

most docs don't know it --- most THCers do know it, and will frequently state that they are on prilosec...

thank goodness my lab doesn't test false positive for prilosec...phew

i ALWAYS ask them what dose of prilosec it is and who prescribed it... usually they mumble the name of their PCP and state they don't remember the dose of their meds (except they ALWAYS seem to know the doses of their controls)... so i tell them that it is easy to solve: i pick up the phone and ask them for the number of their pharmacy so that we can just make sure they are on the right dose...

their story changes as soon as i pick up the phone

why is our population soooo full of liars... do we push them down that path? or is this just the nature of the beast...

sometimes i just want to shove a pencil in my eye .... it would be more enjoyable than the show-downs in my office with bull-sh*ters.

 

[dc2md]

isn't prilosec the newish OTC PPI? so then they wouldn't need a prescription. or am i thinking of another one?

actually, i didn't know about the whole prilosec false positives for THC. is it only THC? and is prilosec the only proton pump inhibitor that will give a false pos.?? and do some UDS really rule out that false positive??

 

[mjl1717]

Thanks guys.. even though I initiated this post I almost missed some of the responses.. But thank you very much..
From what I see pain management can be a very challenging field with a lot of manipulating...

Question--Are there many meds that can acetylate the opiate moiety to make it appear like heroin?
I had someone come into the office for oxycontin.. We did a drug screen..

Now--Xanax as I remember mimicked the BZD..
Pimizode mimicked the barbituate
She was poisitive for a mono acetlyated opiate moeity (although I thought it was diacetyl morphine that was heroin)

According to our drug tech who does the urine screen its a 6 position acetylated opiate moiety that is considered heroin..
The patient although dressed like a hippie claims she detoxed and said this positive screen happened before and an EXPERT told her she will ALWAYS be positive for the 6 position acetylated opiate moiety... Actually I believed her and the doc that I work with believed her..So we let her slide...
But we do urine testing on everyone who comes to the office..Although many complain, claim they cant urinate and cry about this...Any comments?

 

[lobelsteve]

Thanks guys.. even though I initiated this post I almost missed some of the responses.. But thank you very much..
From what I see pain management can be a very challenging field with a lot of manipulating...

Question--Are there many meds that can acetylate the opiate moiety to make it appear like heroin?
I had someone come into the office for oxycontin.. We did a drug screen..

Now--Xanax as I remember mimicked the BZD..
Pimizode mimicked the barbituate
She was poisitive for a mono acetlyated opiate moeity (although I thought it was diacetyl morphine that was heroin)

According to our drug tech who does the urine screen its a 6 position acetylated opiate moiety that is considered heroin..
The patient although dressed like a hippie claims she detoxed and said this positive screen happened before and an EXPERT told her she will ALWAYS be positive for the 6 position acetylated opiate moiety... Actually I believed her and the doc that I work with believed her..So we let her slide...
But we do urine testing on everyone who comes to the office..Although many complain, claim they cant urinate and cry about this...Any comments?

UDS in the office is only screening.
GC/MS is the only reliable testing. Calloway/AIT/Ameritox and a few others.

No pee, No RX. The exit door is over there -->
After a few months of testing word hits the street and they start coming in with clean urine, warmed up to the right temp. THen you have to have a staff member observe them. Then they just go somewhere else because you are the toughest prick in town. The last pain doctors they went to just wrote 3 months of whatever they needed.

 

[Disciple]

Had a patient this week turn up positive for cocaine, and then try the "I ate poppy seeds" excuse.

"Uhhh... yeah.... that's for opiates, not cocaine, read up a little more next time"

While we're on the subject, what about possibilities/causes of false negatives?

I've had a slew of screens negative for opiates this week, from patient's I've been prescribing CIIIs to.


I'm not thinking diversion just yet, more likely they're hoarding the breakthrough meds and not taking them consistently.


Opinions?

 

[lobelsteve]

Had a patient this week turn up positive for cocaine, and then try the "I ate poppy seeds" excuse.

"Uhhh... yeah.... that's for opiates, not cocaine, read up a little more next time"

While we're on the subject, what about possibilities/causes of false negatives?

I've had a slew of screens negative for opiates this week, from patient's I've been prescribing CIIIs to.


I'm not thinking diversion just yet, more likely they're hoarding the breakthrough meds and not taking them consistently.


Opinions?

Before any screen they need to fill out the questionnaire that details all the meds they are taking and when hey last took them.

Otherwise- diversion.