Pain Profiling

[101N]

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Assume working aged adults with work disabling pain on state, wc, or federal disability for the same. In your clinical - expert - opinion which diagnoses are most likely to be associated with aberrant behavior.

Here's my first go at it:

1. 729.1 - FMS
2. 346.0 - Migraine
3. 724.2 - LBP
4. 789.x - Chronic Abd pain
5. 339.x - HA
6. 337.x - CRPS
7. 595.1 - IC
8. Seronegative RA

Please add to the list...

 

[mille125]

Assume working aged adults with work disabling pain on state, wc, or federal disability for the same. In your clinical - expert - opinion which diagnoses are most likely to be associated with aberrant behavior.

Here's my first go at it:

1. 729.1 - FMS
2. 346.0 - Migraine
3. 724.2 - LBP
4. 789.x - Chronic Abd pain
5. 339.x - HA
6. 337.x - CRPS
7. 595.1 - IC
8. Seronegative RA

Please add to the list...

I believe that FMS is a real syndrome but it should not be a diagnosis that qualifies one for disability.

 

[PMR 4 MSK]

Assuming you mean abberant behaviors regarding opioids, I don't find specific ICD-9 codes more associated with misbehavior. The abusers present in as many ways as legitimate patients.

FWIW, I don't believe most of those diagnoses merit opioids anyway, and for most, it is a relative contraindication.

 

[101N]

FWIW, I don't believe most of those diagnoses merit opioids anyway, and for most, it is a relative contraindication.

This is precisely what I'm driving at. Certain diagnoses don't warrant opioids. It's not yet in the literature, but it will be.

 

[deleted185747]

How about you profile this patient:

He's 50 years old, dressed professionally, introduces himself with a firm handshake and gives a brief but un-useful history then pontificates how much he likes your staff, how you're the best doctor in the world and how he is a very important businessman with connections to senators, etc. He is tangentinal and keeps talking about his business exploits and spends as much time as he can becoming your friend and doing what I call "the businessman dance."

What do you think he asked me for?

 

[101N]

How about you profile this patient:

He's 50 years old, dressed professionally, introduces himself with a firm handshake and gives a brief but un-useful history then pontificates how much he likes your staff, how you're the best doctor in the world and how he is a very important businessman with connections to senators, etc. He is tangentinal and keeps talking about his business exploits and spends as much time as he can becoming your friend and doing what I call "the businessman dance."

What do you think he asked me for?

60 virgins?

 

[jettavr6]

How about you profile this patient:

He's 50 years old, dressed professionally, introduces himself with a firm handshake and gives a brief but un-useful history then pontificates how much he likes your staff, how you're the best doctor in the world and how he is a very important businessman with connections to senators, etc. He is tangentinal and keeps talking about his business exploits and spends as much time as he can becoming your friend and doing what I call "the businessman dance."

What do you think he asked me for?

Viagra, Cialis, or Levitra...

Did you check his lithium levels?

 

[lobelsteve]

How about you profile this patient:

He's 50 years old, dressed professionally, introduces himself with a firm handshake and gives a brief but un-useful history then pontificates how much he likes your staff, how you're the best doctor in the world and how he is a very important businessman with connections to senators, etc. He is tangentinal and keeps talking about his business exploits and spends as much time as he can becoming your friend and doing what I call "the businessman dance."

What do you think he asked me for?

Oxycodone sustained release. Oxycontin is such a dirty word.

 

[Jitter Bug]

Clearly something he thought you wouldn't want to give him, or else why butter you up first?

Doesn't need to be opiates or benzos, sometimes I get the hard sell for strange things.

I had a patient once who wanted weekly massage Rx like you would not believe. Referred herself to me for the purpose of getting me to write Rx since her PCP said no. Would not stop arguing for its necessity as long as there was breath in her body. I think she hoped to simply wear me down.

 

[specepic]

How about you profile this patient:

He's 50 years old, dressed professionally, introduces himself with a firm handshake and gives a brief but un-useful history then pontificates how much he likes your staff, how you're the best doctor in the world and how he is a very important businessman with connections to senators, etc. He is tangentinal and keeps talking about his business exploits and spends as much time as he can becoming your friend and doing what I call "the businessman dance."

What do you think he asked me for?

What is short acting opioids with or without tylenol, Alex

 

[bedrock]

Clearly something he thought you wouldn't want to give him, or else why butter you up first?

Doesn't need to be opiates or benzos, sometimes I get the hard sell for strange things.

I had a patient once who wanted weekly massage Rx like you would not believe. Referred herself to me for the purpose of getting me to write Rx since her PCP said no. Would not stop arguing for its necessity as long as there was breath in her body. I think she hoped to simply wear me down.

Why did she have to wear you or her PCP down? Weekly massage could benefit just about anyone.
However, most insurance co won't pay so the point is basically moot, but anyone who wants a weekly massage script from me can have it. Those wanting weekly baskets of Percocet......different story.

 

[Jitter Bug]

(Why did she have to wear you or her PCP down? Weekly massage could benefit just about anyone.
However, most insurance co won't pay so the point is basically moot, but anyone who wants a weekly massage script from me can have it. Those wanting weekly baskets of Percocet......different story.)

I'm a big one for helping my patients develop internal locus of control. Rather than relying on Sheila the massage therapist to manage their chronic pain, I would rather the patient learn to meditate, stretch, and use a theracane.

 

[PMR 4 MSK]

The problem with that Rx, is when she tries to get her insurance to pay for it, she'll say you proclaimed it a medical necessity by writing this Rx, and then expect you to write a LOMN for it. And when that doesn't work, she'll want your staff to spend 30 minutes on the phone with her insurance company. Then expect you to do a "peer-to-peer" call to get it for her. Etc.

Massage is not a medical necessity. It does not warrant an Rx.

You might as well write them an Rx for a Jacuzzi. That feels good, too.

While we're at it, there are "services" a prostitute could provide that could give relief of some of their symptoms also. Surely that deserves and Rx, right?

 

[deleted185747]

While we're at it, there are "services" a prostitute could provide that could give relief of some of their symptoms also. Surely that deserves and Rx, right?

LOL, yeah, for back pain refractory to a TENS unit and acupuncture...


And now for the answer:
The setting is the Kaiser hospital. PMD told him I was the only one who could order the MRI he wanted. I told him 3 weeks of back pain which resolves when he lies down and no neurologic problems does not need an MRI and that MRI's are most useful for planning surgical procedures.

Anyway after he took it to much higher levels in the hospital I was ordered by the higher ups to order the MRI to make him go away.

Sometimes I hate my job

 

[101N]

LOL, yeah, for back pain refractory to a TENS unit and acupuncture...


And now for the answer:
The setting is the Kaiser hospital. PMD told him I was the only one who could order the MRI he wanted. I told him 3 weeks of back pain which resolves when he lies down and no neurologic problems does not need an MRI and that MRI's are most useful for planning surgical procedures.

Anyway after he took it to much higher levels in the hospital I was ordered by the higher ups to order the MRI to make him go away.

Sometimes I hate my job

There are many studies - one even by Deyo - that show patients with back pain want MRIs even though they have no therapeutic value. Your MPS scores affect your salary, be practical and get the MRI.

 

[PMR 4 MSK]

LOL, yeah, for back pain refractory to a TENS unit and acupuncture...


And now for the answer:
The setting is the Kaiser hospital. PMD told him I was the only one who could order the MRI he wanted. I told him 3 weeks of back pain which resolves when he lies down and no neurologic problems does not need an MRI and that MRI's are most useful for planning surgical procedures.

Anyway after he took it to much higher levels in the hospital I was ordered by the higher ups to order the MRI to make him go away.

Sometimes I hate my job

Several times a year I get people who want an MRI that I do not recommend for similar circumstances. I often tell them, I can order it, but I don't guarantee your insurance will pay for it. I don't mind trying an initial pre-auth, but if their insurance denies a pre-authorization, I'm not doing a LOMN or a peer-to-peer call.

 

[pjuer]

Assume working aged adults with work disabling pain on state, wc, or federal disability for the same. In your clinical - expert - opinion which diagnoses are most likely to be associated with aberrant behavior.

Here's my first go at it:

1. 729.1 - FMS
2. 346.0 - Migraine
3. 724.2 - LBP
4. 789.x - Chronic Abd pain
5. 339.x - HA
6. 337.x - CRPS
7. 595.1 - IC
8. Seronegative RA



Please add to the list...

9. Low tooth/tattoo ratio

 

[101N]

9. Low tooth/tattoo ratio

9. H/o meth - or other drug - addiction.

But seriously, why do the experts on this forum know that opioids don't work - and lead to bad behavior - for the diseases listed above. Why isn't this routine knowledge, why isn't it published. Why can't you stop using your gestalt - expert opinion earned by having tried opioids with these diagnoses - and go to the literature to see that, not only do opioids not provide pain relief for some diagnoses, but they actually lead to a host of aberrant behaviors.
Why wasn't this a part of our fellowships, why wasn't it a part of the 2004 or 2005 DEA FAQs?

Why don't Perry Fine, Scott Fishman, Bill McCarburg, et al, talk about this openly?

 

[Jeff05]

type in the names of the people you listed below into google along with "disclosures." Look up Passik, Argoff, Portnoy.

These are the top level shills of opioid producers/distributors in the world. Why would they talk about the fact that there is NO evidence that opioids should be used for noncancer chronic pain (>12 weeks)?

Look at the disclosures for the authorship of the 2009 APS Guidelines. Same story.

Scott Reuben went to prison. These guys are still getting rich.

9. H/o meth - or other drug - addiction.

But seriously, why do the experts on this forum know that opioids don't work - and lead to bad behavior - for the diseases listed above. Why isn't this routine knowledge, why isn't it published. Why can't you stop using your gestalt - expert opinion earned by having tried opioids with these diagnoses - and go to the literature to see that, not only do opioids not provide pain relief for some diagnoses, but they actually lead to a host of aberrant behaviors.
Why wasn't this a part of our fellowships, why wasn't it a part of the 2004 or 2005 DEA FAQs?

Why don't Perry Fine, Scott Fishman, Bill McCarburg, et al, talk about this openly?

 

[PMR 4 MSK]

Plus these academics lead sheltered lives. Most of their patients are pre-selected and are not what you and I see on a daily basis. They do research on patients screened out for risk of drug abuse to show that the drugs they promote have little abuse and that opioids are safe long-term.

I think many of them actually believe the BS they fed us.

 

[powermd]

9. H/o meth - or other drug - addiction.

But seriously, why do the experts on this forum know that opioids don't work - and lead to bad behavior - for the diseases listed above. Why isn't this routine knowledge, why isn't it published. Why can't you stop using your gestalt - expert opinion earned by having tried opioids with these diagnoses - and go to the literature to see that, not only do opioids not provide pain relief for some diagnoses, but they actually lead to a host of aberrant behaviors.
Why wasn't this a part of our fellowships, why wasn't it a part of the 2004 or 2005 DEA FAQs?

Why don't Perry Fine, Scott Fishman, Bill McCarburg, et al, talk about this openly?

Having done my fellowship with SF, I can assure you he has no greater interest in prescribing opiates for non-malignant pain than any of us. He's sheltered by the agreement between the division and the medical center that they don't rx opioids routinely, and if they do, primaries have to take over the prescriptions once the patient is on "stable" dosing. In practice we hardly every started people on opioids in the outpatient clinic. SF is in a position of authority, so he has to be diplomatic with what he says publicly, of course. He focuses his energy on getting people to prescribe with proper risk management, and that will generally screen out the riff raff when done properly. The caveat here being that proper risk management is too expensive in terms of time and reimbursement for most doctors to do well.

I agree though, it would be nice if our leaders would come right out and say "hey, opioids DON'T WORK SUSTAINABLY for non-malignant pain, and CAUSE MORE PROBLEMS THAN THEY SOLVE." Being in sheltered academic environments protects them from making it a personal issue for them. Thus, easy to ignore.

 

[ghost dog]

Having done my fellowship with SF, I can assure you he has no greater interest in prescribing opiates for non-malignant pain than any of us. He's sheltered by the agreement between the division and the medical center that they don't rx opioids routinely, and if they do, primaries have to take over the prescriptions once the patient is on "stable" dosing. In practice we hardly every started people on opioids in the outpatient clinic. SF is in a position of authority, so he has to be diplomatic with what he says publicly, of course. He focuses his energy on getting people to prescribe with proper risk management, and that will generally screen out the riff raff when done properly. The caveat here being that proper risk management is too expensive in terms of time and reimbursement for most doctors to do well.

I agree though, it would be nice if our leaders would come right out and say "hey, opioids DON'T WORK SUSTAINABLY for non-malignant pain, and CAUSE MORE PROBLEMS THAN THEY SOLVE." Being in sheltered academic environments protects them from making it a personal issue for them. Thus, easy to ignore.

One argument could be made is that we see Tx intractable / opioid Tx failures.

In my primary practice, I typically don't see such aberrant opioid behavior as I do in consultations. My regular patients seem to behave themselves quite a bit better. I perform all the usual rigorous screening protocols, and ask all the same questions.

Perhaps I am showing an unconscious bias towards this population?

I will say that I am certainly seeing a significant number of consults where opioids are not doing them any favours, that much is certain.

 

[powermd]

One argument could be made is that we see Tx intractable / opioid Tx failures.

In my primary practice, I typically don't see such aberrant opioid behavior as I do in consultations. My regular patients seem to behave themselves quite a bit better. I perform all the usual rigorous screening protocols, and ask all the same questions.

Perhaps I am showing an unconscious bias towards this population?

I will say that I am certainly seeing a significant number of consults where opioids are not doing them any favours, that much is certain.

Well that explains a lot.

I see plenty of behaviorally normal patients with highly treatable pain problems who have been maintained on opiates for years by PMDs before finally being referred. They're always shocked that these services exist.

The PMDs want to keep their nice normal patients in house. They refer out the troublemakers yet are aghast when we don't want them either.

 

[PMR 4 MSK]

Well that explains a lot.

I see plenty of behaviorally normal patients with highly treatable pain problems who have been maintained on opiates for years by PMDs before finally being referred. They're always shocked that these services exist.

The PMDs want to keep their nice normal patients in house. They refer out the troublemakers yet are aghast when we don't want them either.

I see some behaviorally normal patients with highly treatable pain problems who have been maintained on opiates for years by PAIN DOCTORS before finally looking elsewhere.

Some docs just give up and take the path of least resistance.

 

[101N]

Feel free to start referencing this in you consults...

Opioid use, misuse, and abuse in patients labeled as fibromyalgia.

AuthorsFitzcharles MA, et al. Show all Journal
Am J Med. 2011 Oct;124(10):955-60.

Affiliation
Division of Rheumatology, McGill University Health Center, Montreal, Quebec, Canada; Alan Edwards Pain Management Unit, McGill University Health Center, Montreal, Quebec, Canada.

Abstract
BACKGROUND: As pain is the cardinal symptom of fibromyalgia, it is logical that treatments directed toward pain relief will be commonly used. Analgesic drug therapy remains the traditional treatment intervention for most chronic pain conditions, with a progressive increased use of opioids in the past 20 years. Concerns about efficacy, risk-benefit ratio, and possible long-term effects of chronic opioid therapy have been raised. There is limited information about opioid treatment in fibromyalgia, with all current guidelines discouraging opioid use.

METHODS: A chart review of all patients referred to a tertiary care pain center clinic with a referring diagnosis of fibromyalgia was conducted to evaluate use of opioid medications.

RESULTS: We have recorded opioid use by 32% of 457 patients referred to a multidisciplinary fibromyalgia clinic, with over two thirds using strong opioids. Opioid use was more commonly associated with lower education, unemployment, disability payments, current unstable psychiatric disorder, a history of substance abuse, and previous suicide attempts.

CONCLUSION: We have observed negative health and psychosocial status in patients using opioids and labeled as fibromyalgia. Prolonged use of opioids in fibromyalgia requires evaluation.

Copyright © 2011 Elsevier Inc. All rights reserved.

 

[powermd]

History of having lived in Florida in recent years...

These guys have expectations no straight doctor can match. I keep biting my tongue from telling them they should move back.

 

[lobelsteve]

In Georgia, treating straight FMS patients with opiates fall below the standard of care and can result in a sanction on your license or worse. 😀

 

[PMR 4 MSK]

In Georgia, treating straight FMS patients with opiates fall below the standard of care and can result in a sanction on your license or worse. 😀

But GLBT FMS are ok for opioids? 😱