Psychosomatic pain

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clubdeac

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I've been saying this a lot in my notes lately. Any reason I shouldn't document this? "Based on the lack of objective physical findings on imaging and physical exam, I believe somatization, pain catastrophizing and psychological overlay are likely significant contributing factors in the patient's overall pain presentation. Opioid analgesics and interventional pain procedures are therefore not indicated at this time."
 
I've been saying this a lot in my notes lately. Any reason I shouldn't document this? "Based on the lack of objective physical findings on imaging and physical exam, I believe somatization, pain catastrophizing and psychological overlay are likely significant contributing factors in the patient's overall pain presentation. Opioid analgesics and interventional pain procedures are therefore not indicated at this time."

Do you have a PA in your practice for opioid refills?
 
i think its fine to say
 
sometimes i wonder if patients with somatization, pain catastrophizing and psychological overlay actually do as well or even better with interventional procedures than patients with surgical disease.
for example - patient A has a big disc sitting on a nerve root. gets an injection or three. chances of going to surgery 50/50. has surgery. winds up with chronic back pain. gives up playing soccer. takes it in stride. watches games on TV instead.
patient B has a tiny disc irritating a nerve root, thinks the world is coming to an end because might need surgery, gets an injection or three, pain goes away, thinks a miracle has taken place, goes back to rooting for the Raiders.
which patient did you help more?
 
I've worked with some great, savvy PA's. But there is a tendency in IMP to
use PA's like opioid mules. In my state 6 of the top ten opioid prescribers -
CMS 2013 data - are PAs or NPs working in IPM practices. Given that the
IPM docs themselves - 3 of the top 10 Rx'ers in the state - write for a lot of
opioid this can be a double disaster.

You are obviously not that kind of guy, but nevertheless, use the PA wisely.
If so much pain is central - and it is - do we really need a PA?
 
I've been saying this a lot in my notes lately. Any reason I shouldn't document this? "Based on the lack of objective physical findings on imaging and physical exam, I believe somatization, pain catastrophizing and psychological overlay are likely significant contributing factors in the patient's overall pain presentation. Opioid analgesics and interventional pain procedures are therefore not indicated at this time."

I write this at times. I also typically write "reported pain grossly out of proportion to exam maneuvers"; example- when you gently palate a patient's back fat and flanks and they scream that it's running down their legs and they are crying.
 
I think clarity is good in conclusions. Do you think it's psychosomatic or central pain? Find a cheaper placebo if you think it's psychosomatic.

If it's central pain, opiates and injections won't help much.

I always document a funny exam. Without casting any blame. I had a guy working on a MVC settlement fake a heel-shin-heel maneuver. Did it fine on the right leg, then faked out the left and looked at me with concern in his eyes and said "huh, isn't that interesting?" I documented "heel shin heel was non-diagnostic as patient was unable to bring his left heel across midline to touch the right shin."
 
My office window overlooks the parking lot so I will document if the gait pattern in the office is inconsistent with the observed gait pattern as the patient walks across the parking lot to drive home.
 
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I think clarity is good in conclusions. Do you think it's psychosomatic or central pain? Find a cheaper placebo if you think it's psychosomatic.

If it's central pain, opiates and injections won't help much.

I always document a funny exam. Without casting any blame. I had a guy working on a MVC settlement fake a heel-shin-heel maneuver. Did it fine on the right leg, then faked out the left and looked at me with concern in his eyes and said "huh, isn't that interesting?" I documented "heel shin heel was non-diagnostic as patient was unable to bring his left heel across midline to touch the right shin."
When I think of true "central pain" I think of things like post thalamic (stroke) pain, SCI, phantom limb pain etc. When I think of psychosomatic pain I think of pain out of proportion to exam and imaging most likely due to depression, anxiety/fear, PTSD, OIH, sexual abuse, nicotine use etc.
 
It's fine...until you miss real disease and document instead that the patient was just plain "nuts."Juries hate arrogant doctors...and they'll Google your reviews on "RateMD"...

Where did he say the patient was nuts? Isn't he just documenting that somatic input into the brain is not likely the primary contributor to the patient's symptoms? And, if exam is negative, as is the imaging, and depression screening, FABQ, etc. positive, isn't he accurate?
 
I've been saying this a lot in my notes lately. Any reason I shouldn't document this? "Based on the lack of objective physical findings on imaging and physical exam, I believe somatization, pain catastrophizing and psychological overlay are likely significant contributing factors in the patient's overall pain presentation. Opioid analgesics and interventional pain procedures are therefore not indicated at this time."

Just curious. Do they then get a psych eval/referral to confirm the "likely" part of your conclusion?

On a different note, I imagine (and could be very wrong) that by the time many patients get to pain management, their perceived pain may be more than what is expected?
 
Somatoform disorders are mental illnesses that cause bodily symptoms, including pain. The symptoms can't be traced back to any physical cause. And they are not the result of substance abuse or another mental illness. People with somatoform disorders are not faking their symptoms.

Somatization disorder (also Briquet's syndrome) is a mental disorder characterized by recurring, multiple, and current, clinically significant complaints about somatic symptoms.

A factitious disorder is a condition in which a person acts as if they have an illness by deliberately producing, feigning, or exaggerating symptoms. Factitious disorder imposed on another is a condition in which a person deliberately produces, feigns, or exaggerates symptoms in a person in their care.

Connotations of the term "psychosomatic illness"[edit]
Psychosomatic medicine is not to be confused with the demotic and scientifically incorrect use of the phrase "psychosomatic illness," particularly the influence the mind has over physical processes — including the manifestations of disabilities that are based on intellectual infirmities, rather than actual injuries or physical limitations. These are exemplified by phrases such as the power of suggestion, the use of "positive thinking" and concepts like "mind over matter" to apply to illnesses that are now called somatoform disorders. Such illness is classified as neurotic, stress-related and somatoform disorders by the World Health Organization in the International Statistical Classification of Diseases and Related Health Problems. The field of psychosomatic medicine fell into disrepute clinically due to this incorrect use of this term, which was largely due to the influence of psychoanalytic theory on psychiatric physicians and the inaccurate application by non-specialists in the first part of the 20th century who considered this form of illness to be akin to malingering, thereby further harming the sufferer.[11] For this reason, among others, the field of Behavioral Medicine has taken over much of the remit of Psychosomatic Medicine in practice and there exist large areas of overlap in the scientific research.


Useful definitions for reading this thread.
 
What's the upside to documenting this?

If you write psychosomatic, it's very likely the patient's interpretation is "he says it's all in my head." Cue the f-bombs, trashing you to the referring doc, bad reviews, state medical board complaints, etc.

I just write that I am unable to explain the patient's symptoms based on the objective findings. Hard for a patient to get pissed off at you for that, and anyone reading the note gets the idea.

In truly BIZARRE cases, such as what you see in the Comp world, I'll use that word. It sends the right message to the reader with apparently judging the patient.
 
So, let's not be honest, they could be offended?
Wrong approach. More of need to be honest and courageous and tell the truth.

The more of us that are willing to tell the truth-and we know the truth - the easier it is for all of us to tell it. But as the OP suggested, there is less money in honesty, fewer procedures, fewer narcs, plays havoc with the IPM business model.
 
What's the upside to documenting this?

If you write psychosomatic, it's very likely the patient's interpretation is "he says it's all in my head." Cue the f-bombs, trashing you to the referring doc, bad reviews, state medical board complaints, etc.

I just write that I am unable to explain the patient's symptoms based on the objective findings. Hard for a patient to get pissed off at you for that, and anyone reading the note gets the idea.

In truly BIZARRE cases, such as what you see in the Comp world, I'll use that word. It sends the right message to the reader with apparently judging the patient.
Well I'm now in the VA so I don't give a rat's ass about whether they're mad or if I get referrals. I'll get referrals b/c I'm the best in the hospital 😉 And if I call it what it is, then maybe they'll get help. Saying somatization, pain catastrophizing and psychological overlay are the best ways I know how to say that anxiety and depression are significant contributing factors in their pain experience. If they can treat these underlying comorbidities then maybe their pain will improve. I'm already building a 2-3 month wait list so sending to psych with an accurate diagnosis seems to be the best solution as opposed to using valuable appointments injecting and medicating when neither will help.
 
Why not just hire a mental health practitioner to help screen patients for their appropriateness for pain management?

Having integrated behavioral health (MSW and drug/alcohol counselors) in our group has allowed us triage patients based upon their real needs. The reality is that most patients are referred to pain clinics with undifferentiated pain complaints (fibromyalgia, low back pain, cervicalgia, etc.). Having these patients spend 60 mins at a screening visit with behavioralist can save hours of work in down stream misery....You'll be amazed at what you'll discover.

This model has saved our group a lot of time, misery, and resources....and allowed us to focus on the people who you can actually help and WANT to be helped. I can't think of a down side.
 
I guess it all depends on what your goals are. My goals are to avoid headaches and build my business. I can't help anyone if I'm burned out or hurting for referrals. So for me, it's counterproductive to apply a judgmental sounding diagnosis that I can never prove, but can always be proved wrong later on.

There is probably evidence to support this, but I assume that in order to help a patient, they need to trust you. If they hate you for calling their problem psychosomatic, they won't be very receptive to your offer for a pain-psych referral. On the other hand, if you maintain a non-judgmental stance simply stating you can't explain their symptoms physiologically, they might listen when you suggest a psych based approach. In my experience, first trying it your way, and then mine, that is exactly what happens. But keep doing it your way if that works for you. I love it when patients come crying to me because some doctor pissed them off. More business for me. 🙂

PS for drusso... we have a rough screening process for likely psych cases at the level of referral acceptance/triage. Abdominal/pelvic/unexplained pain, fibro, etc, are generally rejected unless there is something specific we will likely be able to treat. The process works well to keep us full of good interventional candidates.
 
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PS for drusso... we have a rough screening process for likely psych cases at the level of referral acceptance/triage. Abdominal/pelvic/unexplained pain, fibro, etc, are generally rejected unless there is something specific we will likely be able to treat. The process works well to keep us full of good interventional candidates.

@powermd, that is really wise! But, in order for this model to be successful, clinicians must commit to the idea that chronic pain is not a character deficit. Many clinicians are not willing to make that intellectual commitment. Instead, they favor stigmatizing the problem.
 
Why not just hire a mental health practitioner to help screen patients for their appropriateness for pain management?

Having integrated behavioral health (MSW and drug/alcohol counselors) in our group has allowed us triage patients based upon their real needs. The reality is that most patients are referred to pain clinics with undifferentiated pain complaints (fibromyalgia, low back pain, cervicalgia, etc.). Having these patients spend 60 mins at a screening visit with behavioralist can save hours of work in down stream misery....You'll be amazed at what you'll discover.

I like this idea.

Question. Are these evals paid for, require authorization, etc., or is it just a hit to the practice?

Are those set up to be screened selected based on information in records sent by the referring physician?
 
I like this idea.

Question. Are these evals paid for, require authorization, etc., or is it just a hit to the practice?

Are those set up to be screened selected based on information in records sent by the referring physician?

The LCSW is paid for, but not the drug/alcohol counselor. It's ashame that most health plans won't reimburse for drug and alcohol counseling...
 
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I think the timing is right - Rx opioid epidemic + SBIRT - to lobby for funding for CADC
eval funding.
 
I think the timing is right - Rx opioid epidemic + SBIRT - to lobby for funding for CADC
eval funding.

Only possible for Medicaid patients in certain settings...not the private practice setting. No-bid, exclusive service contracts between large physician employers and the State, closed door CCO meetings that don't follow public meeting norms/procedures, and general lack of transparency into the use of tax-payer money for purchasing health services caused our Center to offer it as charity care.

http://www.medicaid.gov/State-resou...Plan-Amendments/Downloads/OR/OR-13-02-Att.pdf
 
A lot of states are resisting Medicaid expansion. I just don't see many going for potentially costly functional restoration based pain programs.

To get a similar result, it may just be easier to institute some simpler measures, like restricting opioids to certain ICD-10 codes (just like procedures), or requiring prior authorization (TAR is the Medicaid term correct?) to start opioids in the first place, or continue them after 6-12 months.

"Sorry, the state doesn't want to cover these meds you're asking for. Guess we'll just have to stick with the Motrin, gabapentin and nortriptyline for now. And I totally get it that you're afraid of needles. Why don't we talk about you quitting smoking today, and maybe starting that pool exercise program at the Y that I mentioned last time?"
 
A lot of states are resisting Medicaid expansion. I just don't see many going for potentially costly functional restoration based pain programs.

To get a similar result, it may just be easier to institute some simpler measures, like restricting opioids to certain ICD-10 codes (just like procedures), or requiring prior authorization (TAR is the Medicaid term correct?) to start opioids in the first place, or continue them after 6-12 months.

"Sorry, the state doesn't want to cover these meds you're asking for. Guess we'll just have to stick with the Motrin, gabapentin and nortriptyline for now. And I totally get it that you're afraid of needles. Why don't we talk about you quitting smoking today, and maybe starting that pool exercise program at the Y that I mentioned last time?"

Only way to improve a patient population that does not want to get better is to limit their choices of coverage. No coverage for opiates, BZD, LESI, SCS. Coverage for Ultram, TCA, Lidoderm, gym membership, psychology or LCSW. If provider offers or gives non authorized treatment and patient pays cash (Norco and I will payout of pocket), then visits get denied payment.
 
@powermd, that is really wise! But, in order for this model to be successful, clinicians must commit to the idea that chronic pain is not a character deficit. Many clinicians are not willing to make that intellectual commitment. Instead, they favor stigmatizing the problem.

I think the concept that chronic pain IS some kind of character deficit relates to the poor coping skills in certain chronic pain patients. As you know, some people just can't cope with discomfort in any form and expect an instantaneous and painless solution requiring no active participation. I cope with these patients by lowering my expectations!
 
Only way to improve a patient population that does not want to get better is to limit their choices of coverage. No coverage for opiates, BZD, LESI, SCS. Coverage for Ultram, TCA, Lidoderm, gym membership, psychology or LCSW. If provider offers or gives non authorized treatment and patient pays cash (Norco and I will payout of pocket), then visits get denied payment.

Not sure it will improve the patient population. Maybe reduce harm.

But hey, you can't help everybody. I guess that's the Un-PC part of it.
 
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