Question from a PCP

[MJB]

I'm curious as to how many fellowship trained Pain Medicine physicians actually prescribe medications, or if what we are seeing in my area is the norm? Basically, referral to a "Pain Management" physician is futile, as unless the patient is wanting a procedure, they are refused any treatment, or denied. We have a significant population on higher doses of chronic narcs that many of us (PCP's) simply are not comfortable managing. These are almost always "inherited" patients....meaning, the PCP looking for help in management did not create the "problem".

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[Aether2000]

There is an increasing body of medical evidence that opioids, while effective for acute pain control, are largely ineffective in the treatment of chronic pain due to tolerance and NMDA receptor activation. The latter actually produces increased pain. Aside from regulatory concerns,
1. There are no high level studies that support the use of opioids in the treatment of chronic pain
2. There are several studies demonstrating long term opioids do not improve pain or function
3. There are several studies demonstrating reduction or elimination of long term opioid prescribing improves pain, function, and depression
4. There are studies demonstrating increasing the dosage of opioids to compensate for tolerance leads to increase in death and serious side effects (falls, fractures, etc)
5. There are studies demonstrating prescription opioids are the gateway drugs to heroin use in up to 80% of heroin users

It is widely believed physicians have created a large number of chemically dependent users of opioids, and the only way out is to gradually withdraw opioids, substituting other avenues of pain control. Compared to every other country in the world, the US vastly overprescribes opioids.

If you are uncomfortable prescribing opioids, that is an excellent beginning of the realization that opioids prescribed chronically may not be in the best interest of patients, and rather referring them for more opioids, the referral should be for opioid withdrawal or reduction with substitution of other pain control methods. Your patients will complain about pain whether they are receiving opioids or not. It is counterintuitive but it is born out in studies and experience of pain physicians.

 

[lobelsteve]

You should see who prescribes in your area based on https://data.cms.gov/browse?tags=opioidmap

Then call a few up and ask them for help weaning patients. Do not ask them to take over prescribing or just do procedures. Ask for a consult and a plan to help the patient come down off the meds.
If the patient refuses the plan, taper them to the CDC guidelines over 4-12 weeks. If they fail, they can go to a detox facility. There is no obligation for ongoing opiate prescribing.

 

[DrCommonSense]

I'm curious as to how many fellowship trained Pain Medicine physicians actually prescribe medications, or if what we are seeing in my area is the norm? Basically, referral to a "Pain Management" physician is futile, as unless the patient is wanting a procedure, they are refused any treatment, or denied. We have a significant population on higher doses of chronic narcs that many of us (PCP's) simply are not comfortable managing. These are almost always "inherited" patients....meaning, the PCP looking for help in management did not create the "problem".

I often take over PCP patients that don't just send me "dumps".

I will often be the "bearer of bad news" for the patient if they are on dosages of opioid medications above that needed for their level of pathology, poor UDS, poor screening for shopping around, etc. I will titrate the patients down significantly from their current dosages at approximately 10% per week.

However, if the PCP just sends the pain management physician patients on >200MED of morphine for "fibro" or "headaches" that are on 5 different psych medications with zero referrals that are on far lower dosages with pathology that is amenable to other treatment modalities, then I won't take over patients for that PCP.

Its a two way street of respect for the PCP and pain physician.

 

[VA Hopeful Dr]

You should see who prescribes in your area based on https://data.cms.gov/browse?tags=opioidmap

Then call a few up and ask them for help weaning patients. Do not ask them to take over prescribing or just do procedures. Ask for a consult and a plan to help the patient come down off the meds.
If the patient refuses the plan, taper them to the CDC guidelines over 4-12 weeks. If they fail, they can go to a detox facility. There is no obligation for ongoing opiate prescribing.

That website is fantastic. For 2014 my % opioid prescriptions was 0.68%.

 

[DrCommonSense]

You should see who prescribes in your area based on https://data.cms.gov/browse?tags=opioidmap

Then call a few up and ask them for help weaning patients. Do not ask them to take over prescribing or just do procedures. Ask for a consult and a plan to help the patient come down off the meds.
If the patient refuses the plan, taper them to the CDC guidelines over 4-12 weeks. If they fail, they can go to a detox facility. There is no obligation for ongoing opiate prescribing.

Interestingly, your liberal homies Robert Dinero and Robert Kennedy came out against CDC saying they are the most corrupt organization in American medical history:

Dunno how accurate the claims the whistleblower is stating about statistical manipulation by the CDC. But your political allies seem to think CDC is garbage.

 

[willabeast]

// We have a significant population on higher doses of chronic narcs that many of us (PCP's) simply are not comfortable managing.//
if you are honest with yourself you may find that you are not comfortable managing this subset of chronic pain patients because your general clinical sense tells you they should not be on this treatment. how you deal with this is IMHO the truest test of character for a doctor. i took a lot of heat from admin for refusing to give chronic opioids to a black male (does that make me racist?) that i sent to CDRP for eval (he found another doc) . also had a young white (attractive) female that i told would need a CDRP eval before i could continue treatment with opioids - daughter of a local doc - patient refused to ever see me again - i got a lot of push back from a lot of docs in her father's specialty (OB-Gyn) - someone else took over prescribing - i was callous in their opinion - patient OD'ed (as in dead) six months later - somehow they thought that may have been my fault also - because she was not given enough meds to take care of her chronic pain - took 15 years but now the pain world has done a 180 degree turn and i clearly did the right thing given current norms. here is the problem - if you are a good doctor and you care about your patients you will find that "current practice" is not going to always be "best practice". "best practices" are sometimes not based on science - it is more like the fashion industry, where leaders dictate the current fashion. trying to fit into the local community and trying to do what is best for the patient is a fine art. rather than send these patients to a pain doctor, suggest sending them to an addiction specialist for an opinion. if addiction med says they are OK, keep them on their current regimen. if not, slowly taper them off. i truly believe your sole responsibility is to do what you think is best for the patient, and being a PCP you know the patient best, not an interventional pain doc who sees the patient one time between procedures, and has little to no interest in taking on a long term questionable opioid user.

 

[101N]

I'm curious as to how many fellowship trained Pain Medicine physicians actually prescribe medications, or if what we are seeing in my area is the norm? Basically, referral to a "Pain Management" physician is futile, as unless the patient is wanting a procedure, they are refused any treatment, or denied. We have a significant population on higher doses of chronic narcs that many of us (PCP's) simply are not comfortable managing. These are almost always "inherited" patients....meaning, the PCP looking for help in management did not create the "problem".

I'm curious as to how many fellowship trained Pain Medicine physicians actually prescribe medications, or if what we are seeing in my area is the norm? Basically, referral to a "Pain Management" physician is futile, as unless the patient is wanting a procedure, they are refused any treatment, or denied. We have a significant population on higher doses of chronic narcs that many of us (PCP's) simply are not comfortable managing. These are almost always "inherited" patients....meaning, the PCP looking for help in management did not create the "problem".

I have a practice that attempts to reduce the harms to these patients. PM you if you want more details. Whether or not you or I inherit these patients doesn't legitimize continuing a dangerous regimen and there a no Good Sam laws that will protect you should there be a bad outcome. See the attached file from CMS.

 

[MJB]

I sincerely appreciate the responses. I'm in a rather difficult situation. I work in an area where there are very few docs in a 30 mile radius, and I have patients that range from having no indoor plumbing and struggle with ANY transportation, all the way to retired Wall Street guys, etc. (very, very wealthy).

My colleague in my clinic was tasked with taking over the population approx. 4 years ago (I started in 2014) and took on a SIGNIFICANT population of "chronic" pain patients that were on anything from Hydros to heavy doses of Oxy and Morphine, Soma, etc.. She has done an admirable job of paring the number down in approx. half, to 400 or so patients. She has gotten appropriate studies and has transitioned those more "appropriate" patients to long acting meds. She announced in May 2016 she would be leaving in May 2017 and has tried in vain to get these patients referred out for "co-management" or even full time management under a specialist, but has hit road-block after road block.

Well, she now has health issues and we are in a crisis situation where we have "me" and some others in medical group that are being asked to take over, or get these folks referred out. I'm firmly in the corner of the above recommendations, and if I end up having to take them, have made it perfectly clear we will be weaning off (I'm simply not a believer in long term, chronic narcotics). Problem being, this all takes a LOT of time...which I don't have, considering I already have a nearly full panel, and the rest of her panel is going to be looking for a medical home as well.

 

[MJB]

And, oh by the way, I work in the ONLY state (that I know of) that doesn't have a Prescription Drug Database program.

 

[BobBarker]

You have the time. These are all level 4 visits. Soma to tizanidine 4mg works well most of the time. Ensure that they have proper diagnosis, proper imaging, and proper specialist consults documented. Taper back on the opioids step wise monthly. If the patients don't like it they can try to find another doctor. Don't mess with the old lady taking 15mg of Norco a day with bad arthritis and renal insufficiency.

 

[101N]

So triage and go after the highest risk patients first: > 120MED, methadone, opioid + benzo/soma. That's where the biggest risk lies.
You must be in Missouri, so make friends with your medical board. Call them up and explain your circumstances. Tell them you
are trying to do the right thing and get their advise.

 

[lobelsteve]

Interestingly, your liberal homies Robert Dinero and Robert Kennedy came out against CDC saying they are the most corrupt organization in American medical history:

Dunno how accurate the claims the whistleblower is stating about statistical manipulation by the CDC. But your political allies seem to think CDC is garbage.

You've got the wrong Dr. I'm a fiscal conservative.

 

[cowboydoc]

And, oh by the way, I work in the ONLY state (that I know of) that doesn't have a Prescription Drug Database program.

Has anyone else found the PDMP is grossly inadequate in data collection? The state of Nebraska's system shows medication information on less than 10% of the patients I have looked up. Nearly all of these should have information, as I have personally prescribed to most of the patient's I have referenced.

 

[Timeoutofmind]

I sincerely appreciate the responses. I'm in a rather difficult situation. I work in an area where there are very few docs in a 30 mile radius, and I have patients that range from having no indoor plumbing and struggle with ANY transportation, all the way to retired Wall Street guys, etc. (very, very wealthy).

My colleague in my clinic was tasked with taking over the population approx. 4 years ago (I started in 2014) and took on a SIGNIFICANT population of "chronic" pain patients that were on anything from Hydros to heavy doses of Oxy and Morphine, Soma, etc.. She has done an admirable job of paring the number down in approx. half, to 400 or so patients. She has gotten appropriate studies and has transitioned those more "appropriate" patients to long acting meds. She announced in May 2016 she would be leaving in May 2017 and has tried in vain to get these patients referred out for "co-management" or even full time management under a specialist, but has hit road-block after road block.

Well, she now has health issues and we are in a crisis situation where we have "me" and some others in medical group that are being asked to take over, or get these folks referred out. I'm firmly in the corner of the above recommendations, and if I end up having to take them, have made it perfectly clear we will be weaning off (I'm simply not a believer in long term, chronic narcotics). Problem being, this all takes a LOT of time...which I don't have, considering I already have a nearly full panel, and the rest of her panel is going to be looking for a medical home as well.

Your posts are very offensive to me. It is not that pain management physicians, only want to do injections, as you stated. All of us are happy to take a rehabilitative multimodal approach with adjunct meds physical therapy mental health etc. that is 21st-century evidence-based medicine pain management. Opioids are not.

Opioids don't work for chronic pain
Tell pts you don't prescribe them for this reason.
Initiate non voluntary weans.
Or punt to the pain specialist for non voluntary weans (and let the pt know ahead of time this is why you are sending them an no more refills from u).
Don't expect other drs to continue opioids if they don't work...why pcps cont to do so is just baffling. This guy is snorting cocaine, he needs to get all his oxy from pain managment! Umm ...detox? Or referral to the addictionologist, just possibly?

I wean a lot of pts for pcps...I'm happy too. But this asinine mentality of "dumping opioid pts" is just ludicrous. Put your big boy pants on. Say no. It doesn't take a lot of time. Just be firm about it and don't go in circles. Offer suboxone if they can't live without opioids.

You will be doing all these people immeasurable good...why we all went to med school after all. That's why I offer to wean them.

 

[MJB]

Next question. We have an anesthesiologist that does ESI, but that's it. If we were trying to get a multi-disciplinary pain center going, I was thinking fellowship trained pain med and Addiction med, with psych. Still researching Addiction Psych to see if that would work. Thoughts?

 

[MJB]

Your posts are very offensive to me. It is not that pain management physicians, only want to do injections, as you stated. All of us are happy to take a rehabilitative multimodal approach with adjunct meds physical therapy mental health etc. that is 21st-century evidence-based medicine pain management. Opioids are not.

Opioids don't work for chronic pain
Tell pts you don't prescribe them for this reason.
Initiate non voluntary weans.
Or punt to the pain specialist for non voluntary weans (and let the pt know ahead of time this is why you are sending them an no more refills from u).
Don't expect other drs to continue opioids if they don't work...why pcps cont to do so is just baffling. This guy is snorting cocaine, he needs to get all his oxy from pain managment! Umm ...detox? Or referral to the addictionologist, just possibly?

I wean a lot of pts for pcps...I'm happy too. But this asinine mentality of "dumping opioid pts" is just ludicrous. Put your big boy pants on. Say no. It doesn't take a lot of time. Just be firm about it and don't go in circles. Offer suboxone if they can't live without opioids.

You will be doing all these people immeasurable good...why we all went to med school after all. That's why I offer to wean them.

I in no way intended to offend. I'm just relaying what we are facing in our area with the folks that offer themselves up as pain management. That's all. As for what I've done in the past? I wean, and have been fairly successful. That said, I'm not sure how I'm going to do that for 400 patients while trying to continue caring for my patients that have medical illnesses I want/need to manage (HTN, DM, Depression, Anxiety, you name it), plus take on another entire panel with similar needs in addition to the pain patients.

Essentially, I'm doing, and planning to do exactly as you've recommended. And I'm trying to learn if anyone is doing much in the way of pain management in the pill form. I appreciate the help and insight. I'm actually happy to see the responses here, as they are far different than what I've experienced.

 

[bedrock]

I'm curious as to how many fellowship trained Pain Medicine physicians actually prescribe medications, or if what we are seeing in my area is the norm? Basically, referral to a "Pain Management" physician is futile, as unless the patient is wanting a procedure, they are refused any treatment, or denied. We have a significant population on higher doses of chronic narcs that many of us (PCP's) simply are not comfortable managing. These are almost always "inherited" patients....meaning, the PCP looking for help in management did not create the "problem".

a few thoughts on your situation

1- you said you live in a rural area. Do you have academic medical center within 2 hours of you? If so and your clinic is overwhelmed, then its fine to send them to the university pain clinic. If not available, well thats the downside of living in BFE.
2-there are bad docs of every stripe in every setting, and you may just have bad pain docs near you. It is certainly looked down on in the pain world to just be a needle jockey and only see patients for procedures, however just seeing patients for med management is not what any pain doc wants to do either. I would call up pain docs within 90 minutes of you and ask if they will see patients that need both med managment and procedures, with the understanding that the pain doc will completely take over those patients. You likely have more patients that need procedures than you think. It's not the patient that should decide if they need a procedure, its you or the pain physician. For starters any patient with radiculopathy or any patient over 50 who says they need opioids for axial-only back pain, and has MRI findings, should be evaluated for procedures to reduce back pain. Send those patients to the pain physicians for both procedures and med management. (however, be aware that many pain physicians won't see anyone on medicaid, as their pain is generally in their head only)

As for help with the other patients, here is pain physician 101
1- You need to start urine testing patients, more of them are selling their drugs or taking illegal ones than you realize. Be sure you send out the urine to the lab, as in office tests are not reliable. It will simplify your life because if the patient is taking illegal drugs then you don't write any more scripts because you don't know if they'll use the last script to OD. If the urine is negative for what they're supposed to be taking, then no more scripts as they don't need a taper as they aren't taking the med anyway, but selling it.
2-no patient can be one more than one mind altering substance, i.e. they can't take benzos or soma or opioids together, as combinations of these three increase risk of OD, car accidents, etc. You can wean the soma quickly, I have them just take it nightly for a week then stop. No patient in the 21st century should take benzos daily. You might allow three 0.5mg xanax in a month for true anxiety attacks, but no more. If they say they have daily anxiety this is best treated with SSRIs or other meds, not daily benzos. If they continue to complain about anxiety, send to psych to manage it without benzos, and be sure that psych knows they can't use them.
3-general rule of thumb is to wean opioids or benzos 10% per week. I generally do one of these at a time, as simultaneously weaning both is hard. However, the 8-12% (10%) wean per week is common and if you patients bitch that it's too much, you know that it isn't. You should be able to wean someone completely off opioids within 2-3 months, quicker for a motivated patient.
4-As others have stated, if you have patients over 50 years old that are working or over 65 years with moderate-severe OA of a joint, or spine, then you may consider writing chronic modest opioid script for them, but no more than Norco 10mg TID , and usually just Norco 5mg BID to TID is enough.
5-keep in mind that if they don't meet that moderate-severe joint/spine degeneration criteria, they don't really require opioids, even if they think they do. Also unless medically contraindicated, anyone with pain in a peripheral joint severe enough to require opioids, should see ortho to get a joint replacement. If they aren't willing to get the joint replacement, then they don't really need opioids.
This is different for the spine of course as I'm sure you know that lumbar fusions are a bad idea 95% of the time.

 

[NJPAIN]

I in no way intended to offend. I'm just relaying what we are facing in our area with the folks that offer themselves up as pain management. That's all. As for what I've done in the past? I wean, and have been fairly successful. That said, I'm not sure how I'm going to do that for 400 patients while trying to continue caring for my patients that have medical illnesses I want/need to manage (HTN, DM, Depression, Anxiety, you name it), plus take on another entire panel with similar needs in addition to the pain patients.

Essentially, I'm doing, and planning to do exactly as you've recommended. And I'm trying to learn if anyone is doing much in the way of pain management in the pill form. I appreciate the help and insight. I'm actually happy to see the responses here, as they are far different than what I've experienced.

I commend you for reaching out to better understand our perspective on things. A common misconception is that pain management/medicine involves controlling pain by whatever means necessary. That was the thinking and teaching of "a few well meaning cancers doctors" that dumped up into this deep dark hole. Hence, you have 400 patients on chronic opioid therapy in a rural practice. That is beyond ridiculous. Someone along the way should have pulled the emergency brake and said - oh no I won't do that.
I agree with all that has been said. This is a therapy that is not evidence based and therefore it is, as it should be, dead. The solution is not to kick the can to someone else as that is not the correct thing for the patient and not something that another physician wants to deal with. It is like having 400 patients with borderline personality disorder and trying to find them a home in another practice because you cant help them and need to attend to your other patients who can and want to be helped.
I would flat out tell the patients that opioids have been taken off of the menu because we now know that there is no evidence to support their use. I would tell them that a taper will start immediately (10%/week is truly reasonable). I would tell them that they are free to find another doctor if they wish but that you will not assist with that as that will only delay the inevitable. If they are successful in finding someone they will only revisit this issue when he/she looses their licence, gets arrested, runs out of procedures to trade for pills, etc. There are large hospital systems with hundreds of these patients that have been trying to hire "pain medicine physicians" to manage these patient populations. Most have been trying to enlist someone for years without success. Those that have found a physician have watched them burn out in a year or two.
As much as you may hate to tell your departing colleague that she is on her own it might be best to tell her to tell her patients that as of May 2017 opioids are removed from the formulary so tapering starts today. Best of luck. I'm confident that in the end you will have a better practice and more time to spend on important issues with your patients.

 

[kstarm]

... It is not that pain management physicians, only want to do injections, as you stated. All of us are happy to take a rehabilitative multimodal approach with adjunct meds physical therapy mental health etc. that is 21st-century evidence-based medicine pain management...

I am a pain physician I have to disagree. In the metro area I am in I would guess it is 3 to 5-1 straight IPM docs to those that you could call multidisciplinary. Nearly all the fellows I have worked with want to learn and do as many procedures as they can and make that the main part of their practice. I think with how lopsided the reimbursement is for procedural medicine vs a "rehabilitative multimodal approach" it makes sense why people go this route, but I think the OP experience of finding "injectionologists" or "narcs for shots docs" is prevalent throughout many parts of this country.

 

[neutro]

1. You do have time. we are all busy and these are difficult patients. Saying you're busy tells me that you really don't care. Read the current literature, evidence and philosophy behind opiod rx, and CDC guidelines and re-evaluate all of your patients and understand their disease process. Thats what we do. Call the surgeons, pain doctor, oncologist, whoever involved and take responsibility of your patients after coming up with a plan and coordinate their care.
2. If you don't have state narcotic registry, you can use dr first med hx profile. It costs $700 for a year's membership. Its sometimes better than narcotic registry as it will show prescriptions from multiple states/providers. We use both this and state narcotic registry and compare the two.
3. UDS with GC-MS everyone. Any aberrancies, they're out. BZD and opioids ONLY after risk stratification.
4. FM, migraines are not treated with opioids.
5. Localized pain issues, such as joint problems, etc need to be referred to ortho to correct the issue.
6. Patients need to undergo PT, CBT, weight mgt and smoking cessation and optimization of health before opioids are considered. Most PCPs do not do these basic things and expect the pain doctor to send for bariatric surgery consult.
7. Dont agree to take any patients on opioids on first visit until a detailed eval.
8. Do not rx meds first visit. First visit is for consult only.
9. Injections are rarely curative. They are meant to assist with physical rehabilitation and analgesia while the patient works to improve their underlying condition causing pain. Expecting anything else will be foolish. You may not be able to do injections, but you can certainly send the patient for other appropriate pain mgt modalities, such as accupuncture, massage therapy, CBT, psych eval, weight reduction help and smoking cessation. Unlikely that their pain will improve if these underlying issues are not corrected.

I also find the tone of your post quite offensive, and the use of the word "futile" quite disappointing. In my opinion, PCPs have the most power and influence in managing this problem, but because of their consultorrhea and terrible habit of referring everything to specialists even for basic things (thereby creating more work for everyone and raping medicare while at it), they do not want to do it and it seems that this opioid problem will persist. We have a PCP who does not want to refill protonix for simple GERD and wants the GI doctor to do it. It has become the norm within FM/IM training apparently to consult everyone and not take any real responsibility.
You cannot expect ~400 fellowship trained pain physicians graduating per year to manage ALL opioid patients in the U.S along with the ones we have already. It is a numerical impossibility. There just aren't enough addiction medicine physicians or psych. doctors to manage this.

It needs to start at the PCP level and the difficult patients can be referred to pain doctors WITHOUT any expectation that we will continue their opioids. You are sending the patient for an evaluation, not to show up and get scripts so you dont have to deal with it.

10. Oh and document everything.

 

[101N]

The OP is spot on. That's why when you go through the CMS database on opioid prescribing you find that the top prescribers are our PAs/NPs so that we can stay in the procedure suite.

http://www.rep-am.com/lifestyle/2016/09/11/training-in-pain-management-is-not-a-top-priority/

Still, Becker, who researches pain management at Yale, does not believe more pain specialists will solve the problem. “Yes, there are not nearly enough ‘pain specialists,'” he said. “But really pain specialists are not suited to managing chronic pain. Historically, they have been more interested in highly reimbursed procedures that aren’t really what improve outcomes in patients with chronic pains.” He pointed to epidural steroid injections for the back, which, he said, have not been demonstrated as effective for long-term relief. “We need more generalists who are fluent in the treatment of chronic pain,” he said.

 

[Ligament]

You have no obligation to continue the prescription of inappropriate medications. You have no obligation to perform the opioid wean yourself. None of these patients will die from lack of opioids, while some may die from continuation of them.

You certainly cannot, or should not, manage this many opioid patients yourself, particularly since they are not appropriate (even at my peak of opioid prescribing, I did not have this many chronic opioid patients in my practice).

I'd suggest you:
1. Make a referral to an addictionologist for each of these patients for a gentle wean. Specify whether they are "dependent without signs of abuse or addiction" or "addicted"
2. Send a list of opioid addiction treatment centers in your state so they can seek treatment elsewhere if they don't like your referral. Send it certified mail. Document this in each patients chart.
3. Send a letter telling them they will receive no more opioids beyond X date, period. I think a 2 month window would be sufficient.
4. Send a letter to your addiction center of choice that they should expect to see a large bolus of patients from your clinic.
5. If any of them are addicts or diverting, cut them off immediately, no "taper" supply of opioids over that two month window. Zero opioids period.

Your patients will be grumpy, pissed off. In the end they will have LESS PAIN, IMPROVED FUNCTION, and LESS COMORBIDITY.

I sincerely appreciate the responses. I'm in a rather difficult situation. I work in an area where there are very few docs in a 30 mile radius, and I have patients that range from having no indoor plumbing and struggle with ANY transportation, all the way to retired Wall Street guys, etc. (very, very wealthy).

My colleague in my clinic was tasked with taking over the population approx. 4 years ago (I started in 2014) and took on a SIGNIFICANT population of "chronic" pain patients that were on anything from Hydros to heavy doses of Oxy and Morphine, Soma, etc.. She has done an admirable job of paring the number down in approx. half, to 400 or so patients. She has gotten appropriate studies and has transitioned those more "appropriate" patients to long acting meds. She announced in May 2016 she would be leaving in May 2017 and has tried in vain to get these patients referred out for "co-management" or even full time management under a specialist, but has hit road-block after road block.

Well, she now has health issues and we are in a crisis situation where we have "me" and some others in medical group that are being asked to take over, or get these folks referred out. I'm firmly in the corner of the above recommendations, and if I end up having to take them, have made it perfectly clear we will be weaning off (I'm simply not a believer in long term, chronic narcotics). Problem being, this all takes a LOT of time...which I don't have, considering I already have a nearly full panel, and the rest of her panel is going to be looking for a medical home as well.

s

 

[DrCommonSense]

The OP is spot on. That's why when you go through the CMS database on opioid prescribing you find that the top prescribers are our PAs/NPs so that we can stay in the procedure suite.

http://www.rep-am.com/lifestyle/2016/09/11/training-in-pain-management-is-not-a-top-priority/

Still, Becker, who researches pain management at Yale, does not believe more pain specialists will solve the problem. “Yes, there are not nearly enough ‘pain specialists,'” he said. “But really pain specialists are not suited to managing chronic pain. Historically, they have been more interested in highly reimbursed procedures that aren’t really what improve outcomes in patients with chronic pains.” He pointed to epidural steroid injections for the back, which, he said, have not been demonstrated as effective for long-term relief. “We need more generalists who are fluent in the treatment of chronic pain,” he said.

The purpose of the injections is to get them to improve through Rehab techniques where they are having too much "pain" to undergo.

This is a common problem we will have with patients that come into our multidisciplinary clinic where we offer CBT, acupuncture, physical therapy, etc.

That argument is dishonest at best about "long term relief" because nothing really offers "long term relief" by itself in many cases. Its the combination of modalities that has the highest success rates.

 

[DrCommonSense]

The OP is spot on. That's why when you go through the CMS database on opioid prescribing you find that the top prescribers are our PAs/NPs so that we can stay in the procedure suite.

http://www.rep-am.com/lifestyle/2016/09/11/training-in-pain-management-is-not-a-top-priority/

Still, Becker, who researches pain management at Yale, does not believe more pain specialists will solve the problem. “Yes, there are not nearly enough ‘pain specialists,'” he said. “But really pain specialists are not suited to managing chronic pain. Historically, they have been more interested in highly reimbursed procedures that aren’t really what improve outcomes in patients with chronic pains.” He pointed to epidural steroid injections for the back, which, he said, have not been demonstrated as effective for long-term relief. “We need more generalists who are fluent in the treatment of chronic pain,” he said.

Also, I could make the same argument about everything PCPs do.

BP pills, insulin, statins by themselves are rarely curative and show little long term benefit unless physicians make their patients lose weight, control diet, stop smoking, etc. Basically just masking the symptoms instead of curing the underlying problem.

Just pushing pills during a 5 min office visit rarely is curative. So we really don't need more PCPs but we need more nutritionists, CBT, etc to really "cure" patients rather than mask their symptoms with pills.

PCPs basically just want to make money through fast 5 min office visits that are far higher reimbursed than nutritional consultations, CBT for weight loss/smoking cessation, etc. The often add in highly reimbursed lab testing services, imaging services, EKGs, etc to supplement their income which doesn't help the vast majority of patients they are testing.

It is far more lucrative for them to just push statins or BP pills that would be wholly unneeded for most patients if they were just had prevention of their initial bad health behaviors.

 

[101N]

Next question. We have an anesthesiologist that does ESI, but that's it. If we were trying to get a multi-disciplinary pain center going, I was thinking fellowship trained pain med and Addiction med, with psych. Still researching Addiction Psych to see if that would work. Thoughts?

Addiction psych would be great, but getting one of those rare birds in a rural environment might be a tough sell. There are no dual pain/addiction med fellowships. There is a lot more $ in the pain end than the addiction end so most - not necessarily all - of the pain folks you recruit will want to focus on
procedures.

Here are some alternatives that - don't make a lot of money for your organization - but are forward thinking.

1.
2.
3. https://www.nytimes.com/2016/05/12/us/opioids-addiction-chronic-pain.html?_r=0

 

[MJB]

Interestingly enough, I have the tough conversation with literally every pain patient taking anything but the occasional Norco. I have successfully weaned every person from chronic long acting, high dose narcotics that has come to me (not a lot) in the last 2 years. My worry is being inundated with well over 100 of these types (Embeda, OxyContin, Morphine, etc.)

I do appreciate the help. As for referring out or dumping...did I mention I do rural primary care? I handle 90% of stuff right here in our office. Referring out only for procedures I'm not credentialed for our for true consultation on problems I'm either having trouble with, or don't have enough knowledge of. So, I guess I'm a little offended. Don't throw all PCP's into one bucket.

I'm only commenting on experiences we've had with pain medicine in our small area. I appreciate the insights. I got mostly the exact feedback I expected, and have communicated that to appropriate people. Again. Thank you.

 

[SeniorWrangler]

I think it's worth while to reach out to some of the pain docs in your community to try to find one that is willing to work with you. A pain doctor whose practice is all about injections is probably not going to change their practice pattern to suit you.

I personally don't mind being the "bad cop" on a consultation where the referring provider wants me to render an opinion, but I make it clear to the patient early on that this is what I'm doing and that they are not, under any circumstances, walking out of the exam room with an opioid prescription.

 

[MedZeppelin]

Do any contributors have a link to any recent studies regarding the changing view of opioid use in chronic pain?
Thx