Reddit PCP forum - derogatory remarks about pain

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nerve zapper

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Just an FYI. I was pretty disheartened to read this post on reddit about pain docs refusing to prescribe opioids. MDs and DOs are saying stuff like

"There is almost no procedure where they are the top of their field compared to Ortho, neurosurg, IR."

"At this point [the benefit of a pain doc is] nothing. None of the procedures they offer are they comparably trained in comparison to other specialties. The selling point used to be multimodal pain management, but procedure only means you are getting the second best choice for the procedures they want to do and not touching meds with a ten foot pole."

"Yet they continue with their epidural injections that don’t work and spine stimulators that don’t work and ablations that don’t work."
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I guess as a follow up, when I finish fellowship and am starting practice and meeting PCPs in my neighborhood, how can I confront these misconceptions?

How can I convey my practice philosophy of minimal opioids (given lack of evidence and safety concerns vs interventions which have pretty decent evidence) to a doc that fundamentally disagrees with that philosophy?

Some of these comments are expressing frustration that the PCPs don't have advanced training in high dose opioid mgmt. Well in PM&R residency I've had 0 training in chronic opioid mgmt, and I don't think I'm going to get much in fellowship...
 
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remind them that we do do pain management to assist, not pain pills or pain medicine per se.

ask them to think about how their practice would be if, instead of just 1 or 2 people demanding narcotics, if every single patient coming to their office were to demand narcotics from them. interspaced between these patients would be DOH and DEA agents attempting to catch them inappropriately prescribing opioids.



if they want a doctor who is willing to take over these train wrecks that many of them have caused, then they should petition the government agencies to develop a pain opioid doctor and system who is immune from government prosecution on one side and homicidal addicts on the other.


---
practically speaking, it is a good idea to let them know that you do not have an answer, but you can help them if they choose to prescribe medications, but offering adjuncts, offering monitoring services, and offering counselling to the patients they choose to prescribe.

my philosophy is that i am not going to cure someones chronic pain, but hopefully i can help patients live better with their pain, in a way that is safe and does not violate my Hippocratic Oath to do no harm (of which opioid therapy indubitably can cause)
 
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nerve zapper said:
Just an FYI. I was pretty disheartened to read this post on reddit about pain docs refusing to prescribe opioids. MDs and DOs are saying stuff like

"There is almost no procedure where they are the top of their field compared to Ortho, neurosurg, IR."

"At this point [the benefit of a pain doc is] nothing. None of the procedures they offer are they comparably trained in comparison to other specialties. The selling point used to be multimodal pain management, but procedure only means you are getting the second best choice for the procedures they want to do and not touching meds with a ten foot pole."

"Yet they continue with their epidural injections that don’t work and spine stimulators that don’t work and ablations that don’t work."
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My experience in the community is that PCPs are very appreciative of the work we do. Just as in any other avenue of life, the internet gives people a place to anonymously vent their spleen.
 
I agree with some of the comments. I do think the shift to financially favor interventional medicine including pain procedures has been a detriment, especially for chronic pain patients. If the finances favored comprehensive pain mgmt and especially more robust coordination with social work, psychitary and addiction medicine patients would be better off, but that isn't the reality. The economics are straight forward, it is hard to understand all the incredulity on the PCCs, people do what makes money and that is humans across the board. A lot of comments are misconceptions, and comparing opioids to insulin is just so far from accurate. If you do good work and build relationships you won't have a problem making it.
 
RoloTomassi said:
Don't take online comments to heart
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a lot of those are from "care providers" who clearly have different perspectives (ie limited knowledge) on opioids - including a few that seem to identify as advanced practice providers.

===
and i do agree with kstarm.

we are judged by how much money we bring in, how many rvus we perform, how much we inject, not the type of care.

but that doesnt obviate the "they dont do anything" negativity of many of those posts.
 
Dont take personally. They gained this perception from real world experiences and became frustrated because ultimately they have to continue seeing difficult pain patients; weather your management works or not. Most IM/PCP referrals to pain come with the implicit expectation that you entirely take over their pain management; meds, PT recs, procedures. Lots of their referrals are frankly opioid continuation, opioid taper, procedure refusing patient dumps. Legit patients tend to come from PM&R, ortho, and spine. The issue is they usually play a 1 for 1 referral trade with you; unless you work for their group.
 
Reddit is pretty pro-opioids compared to here. I'm a PCP and when I saw that post and the comments I just started shaking my head. I few thoughts I had after reading the whole thing...

Weaning a patient off of opioids isn't hard. It just isn't. Yes you'll be the "bad guy", but that's often times the role doctors have to take to practice good medicine. Most patients get irritated or worse when I start them on insulin, but I'm not going to let their blood sugar of 400 be treated with metformin monotherapy.

I do agree that 100% procedural practices are a problem. If I'm honest, if I find out you're doing that I'm not going to send you any more patients. If you don't really want to do opioids, I'm fine with that. But there are other medication options, some of which I'm not all that familiar with, so I do expect y'all to do some medication management. Y'all can also order more directed PT than I am familiar with.

Most of them time, chronic opioids are a bad idea. If you disagree, then you can write them. My DEA number is every bit as good as yours so if I thought opioids would help a patient I can prescribe them.
 
I don't think we (Pain Management doctors) should be upset about what other doctors say about us. We have it pretty good TBH.

PCP's deal with A LOT of BS. They make less money than we do, in many cases work more hours and they're trying to coordinate care amongst multiple specialities. It's hard, very hard actually.

All they know is they sent Mrs. Jones to you, nothing happened and she's back with the same problems you're supposedly able to treat.

Furthermore, if you're not offering some form of community physician outreach you're doing it wrong. We do a CME event every other year or so. PCP's come and we lecture on a few topics. Answer Qs. Show our face. It makes a huge difference.
 
Pain patients are difficult.. when you don’t make the problem go away for PCPs et al it often annoys them. It’s funny how their prescription pad works just like mine but it annoys them that we won’t prescribe.. if they feel so strongly why do they need someone else to do it? Oh yeah I remember liability.. please hold this hand grenade I pulled the pin on.. I’ll be right back!
 
Laryngospasm said:
Pain patients are difficult.. when you don’t make the problem go away for PCPs et al it often annoys them. It’s funny how their prescription pad works just like mine but it annoys them that we won’t prescribe.. if they feel so strongly why do they need someone else to do it? Oh yeah I remember liability.. please hold this hand grenade I pulled the pin on.. I’ll be right back!
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Many feel like the pain doctor should manage the pain, and if that means pain meds well…The pain guy manages the pain.

Never be angry with PCPs.

Edit - BTW, the most egregious opiate regimens I’ve ever seen are PCPs. If the PCP digs a giant hole, I’m not bailing them out.
 
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MitchLevi said:
Many feel like the pain doctor should manage the pain, and if that means pain meds well…The pain guy manages the pain.

Never be angry with PCPs.

Edit - BTW, the most egregious opiate regimens I’ve ever seen are PCPs. If the PCP digs a giant hole, I’m not bailing them out.
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But what about the concept of treating the underlying pain?

If their pain is from RA or chronic pancreatitis or central pain syndrome, it is reasonable to expect rheumatologist, gastroenterologist and neurologist to manage the pain associated with these conditions. If anything, they are the better specialists to do it in my opinion.
 
I recall a med school lecture from a psychiatrist where he mentioned his brother was pretty dismissive of his career in psych. Then one day his nephew developed signs of schizophrenia and suddenly his brother saw and appreciated his value. When people talk smack about pain management, I just bless their heart and hope they don’t need me in the future.

Very few treatments in medicine “cure” anything 100%.
 
MitchLevi said:
Many feel like the pain doctor should manage the pain, and if that means pain meds well…The pain guy manages the pain.

Never be angry with PCPs.

Edit - BTW, the most egregious opiate regimens I’ve ever seen are PCPs. If the PCP digs a giant hole, I’m not bailing them out.
Click to expand...

What do you do when patients have nowhere to go? Their PCP who's been giving everyone Norco, Soma, and Benzos for years suddenly has their prescription privileges revoked and noone else will take them.

Serious question. I'm struggling with this now. I don't like the idea of leaving them to withdraw.
 
IYKYK said:
What do you do when patients have nowhere to go? Their PCP who's been giving everyone Norco, Soma, and Benzos for years suddenly has their prescription privileges revoked and noone else will take them.

Serious question. I'm struggling with this now. I don't like the idea of leaving them to withdraw.
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Referral to addiction specialist.. they have the training to deal with these people.
 
I wrote a response, but then had Chat GPT rephrase it in the style of Dave Chapelle. Much more diplomatic!

"Alright, let's keep it real for a sec. You know what's up when you send those "pain management" referrals, right? You're like, "Hey, Doc, can you deal with this hot mess for me?" But don't front like it's just about expertise. We all know some of those patients are more about their drama than actual pain relief. And you, dear doc, you're tired of scribbling in your notes, "Yeah, let's get this guy off oxy... someday."
Listen, if the opioids ain't cutting it, why keep dancing around it? Cut 'em off. Don't wanna deal with that mess? Simple. Don't start it. And for the love of sanity, don't allow someone else's train wreck on your panel. You got choices, man. Be picky about who you take on.
But hey, if you genuinely think those opioids are doing some good, ain't no shame in reaching out for backup. Hit up the pain doc for some pointers on med management. They're supposed to know their stuff, right? So, let's collaborate, people. It's a team effort."
 
IYKYK said:
What do you do when patients have nowhere to go? Their PCP who's been giving everyone Norco, Soma, and Benzos for years suddenly has their prescription privileges revoked and noone else will take them.

Serious question. I'm struggling with this now. I don't like the idea of leaving them to withdraw.
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Refuse consult - you have nothing to offer.
If they make it through your screening, you get to be the bad guy. Regimen is not medically appropriate ever. It is a red flag for DEA and prescribing that way should trigger an audit and investigation. Do you want to lose your license like the last doc for this patient. A patient on this regimen is an addict. And they are never unwilling participants. They know what they are doing despite them crying ow it is not their fault.
 
IYKYK said:
What do you do when patients have nowhere to go? Their PCP who's been giving everyone Norco, Soma, and Benzos for years suddenly has their prescription privileges revoked and noone else will take them.

Serious question. I'm struggling with this now. I don't like the idea of leaving them to withdraw.
Click to expand...
Not your problem. I realize what I'm saying almost sounds like double speak by the way. I just think PCPs should be given quite a bit of grace by Pain Med doctors.
 
IYKYK said:
What do you do when patients have nowhere to go? Their PCP who's been giving everyone Norco, Soma, and Benzos for years suddenly has their prescription privileges revoked and noone else will take them.

Serious question. I'm struggling with this now. I don't like the idea of leaving them to withdraw.
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if you do see them:

help them with withdrawal symptoms while kindly informing them that you are here to support them in the situation they find themselves in, while you cannot prescribe these medications for them, because of the exact situation they find themselves in. in the long run, not just from the literature but from my personal N of probably 1000+, these patients are better in the long run.



on one end of the spectrum - reassurance and listening for those who have mild or no symptoms.

the other end - refer to drug detox or if you are comfortable, start suboxone or butrans patch.


in the middle - review how much meds they have left. give suggestions on how they can reduce their symptoms by decreasing their meds appropriately. you are not prescribing, but you can suggest that they cut back their remaining supply.

for opioid withdrawal - ibuprofen, tizanidine, clonidine if appropriate, increase fluids and hydration, contact info for detox programs, reassurance that while symptoms are bad, very few people undergo serious harm from opioid withdrawal.

benzo withdrawal is potentially more concerning, and may prompt referral to ER.
 
IYKYK said:
What do you do when patients have nowhere to go? Their PCP who's been giving everyone Norco, Soma, and Benzos for years suddenly has their prescription privileges revoked and noone else will take them.

Serious question. I'm struggling with this now. I don't like the idea of leaving them to withdraw.
Click to expand...
My office isn't the appropriate place for this patient. This is not a pain problem, this is a polypharmacy dependence problem. I decline the referral and recommend sending the patient to addiction medicine or to inpatient detox.
 
I've marketed to many many PCPs and almost every time I get asked about opioids. The problem is that the pain management world has gotten the message about opioids not being effective treatment for chronic non-cancer pain, but the older/established PCPs in general haven't. I get that PCPs often get stuck with needy patients who constantly complain, and it's hard when there is no good answer to their problem, but that doesn't mean their patient should get inappropriate/dangerous treatment just to satisfy them.

My refusal to take over or start opioids isn't an abdication of duty or trying to maximize profits, it's about appropriate treatment. My office offers pain psychology, pain-focused occupational therapy, physical therapy, and interventional procedures. These are all appropriate treatments for various types of pain. We also offer medication recommendations if appropriate. However, the more routine medications that I manage myself means longer wait times to get in to see me for someone I can help that they can't.

If I'm repeatedly confronted about this, I ask them if they expect the interventional cardiologist to handle routine blood pressure medications or that the endocrinologist write for routine metformin. The answer is no, and those are even appropriate medications.
 
3 other pain docs in area
- 2 don’t do any opiates
- 1 puts intrathecal pumps if sustained opiates
- PCP sent me patient who was taking flight (by plane to other side of country) to her old doc q2 months for opiates (<30 OME)

Maybe, pendulum has swung too far? She’s had chronic cervical radic and shoulder pathology willing to get MRI and work up, ready to go to PT

I disagree with their derogatory comments about pain medicine
There is evidence for kypho
We’re best at spine injections eventually by sheer nature of volume

To other forum members
- what can we do better that neuro IR, sports med, PMR cannot do better?
- also, if facility based injection on Medicare, opiates pay better than injection (ESIs)
 
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What do we do better? I think that largely depends on the individual. Some docs are needle jockeys no better than CRNAs and have no desire to add additional value (except to their bank accounts). These are the guys who give the rest of us a bad rep.

Where do we do best?

First, we are 100% focused on pain diagnosis. Every case we see is about that, not primary care, not rehab, not stroke evaluation, or MS workups etc. IR are basically needle jockeys with an excuse- others do the workup and they do the procedure.

Second, we are masters of context. We have a huge toolbox and get constant feedback on how well it works. Injections, meds, surgery, psych, PT, watchful waiting, I think we have a better understanding of the indications and effects of these than any other specialty.

Finally, there is something to be said for the vast body of experience we have doing diagnostic injections with local, and other procedures that give immediate results (like kypho). We get instant feedback on our diagnostic ideas in a way no other specialty gets. Over thousands of cases, that becomes clinical wisdom. We become Tom Hanks in Castawy hitting the fish from 60 feet away with a spear.
 
SpineandWine said:
To other forum members
- what can we do better that neuro IR, sports med, PMR cannot do better?
- also, if facility based injection on Medicare, opiates pay better than injection (ESIs)
Click to expand...
I have no idea, because I have spent zero time shadowing these other people. I don’t have to be the best. I’m the best option the patient has for now and I take that seriously.

There are very few PM&R docs who aren’t pain and also practice outpatient medicine so I’m not sure how PCPs can refer to them. You can refer to sports medicine and then they’ll refer to me for the shot. You can refer to IR directly for procedure and that’s definitely going to decrease the success rate of treating the correct diagnosis, but I’m sure the injection will be performed correctly.
 
It always depends on the person, I agree.
However, it’s PCPs feeling they’re not getting benefits for patients when they send them to pain.

Does SCS work- our mantra has always been, “what other option is there as revision is not better idea.”

I don’t see PCPs making these comments about Orthopoedic surgeons, cardiologist, GI docs, Endocrinologist (diabetelogist- even though patients may still have high HgbA1c).

Issue is that patients may do everything we ask/recommend and patients may still not improve (SCS failure, RFA failure, ESI failure, adjunct failure) and they may get QOL with low dose opiates but we throw our hands up and say see PCP

if patient follows strict recommendation of nutritionist and/or endocrinologist, they usually improve- not always case for PT, etc.
Were more like psychiatrist in that aspect

I don’t think Neuro IR is better than pain with regards to TFESI and/or RFA usually - also, they usually don’t have clinic
 
SpineandWine said:
It always depends on the person, I agree.
However, it’s PCPs feeling they’re not getting benefits for patients when they send them to pain.

Does SCS work- our mantra has always been, “what other option is there as revision is not better idea.”

I don’t see PCPs making these comments about Orthopoedic surgeons, cardiologist, GI docs, Endocrinologist (diabetelogist- even though patients may still have high HgbA1c).

Issue is that patients may do everything we ask/recommend and patients may still not improve (SCS failure, RFA failure, ESI failure, adjunct failure) and they may get QOL with low dose opiates but we throw our hands up and say see PCP

if patient follows strict recommendation of nutritionist and/or endocrinologist, they usually improve- not always case for PT, etc.
Were more like psychiatrist in that aspect

I don’t think Neuro IR is better than pain with regards to TFESI and/or RFA usually - also, they usually don’t have clinic
Click to expand...

This is an area where a pain doc has to get comfortable being uncomfortable.

Unlike ortho, GI, endo, cards, etc, which have objective endpoints to measure success, our endpoint is entirely subjective- an improved sensory and emotional experience. It's subject to a lot that we have no control over, and that's before we start talking psych overlay and secondary gain.

PCPs being upset has less to do with us, and more to do with being spoiled at some point by pain docs who would bury the unwanted bodies.
 
SgtThunderfistMD said:
Like 5% of my patients from PCP's have even completed PT before they see me for a consult. Once they work on their ability to motivate patients to complete that, they can judge me for my efficacy.
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Agreed. I’m shocked at how few PCPs actually do primary care.

If someone presents to a pcp with a spine or peripheral joint problem, the pcp should do some primary care which means ——order PT +/- a prescription nsaid/gaba/muscle relaxer, depending on the issue.

40% of the time those patients will get better and will not need a specialist referral. And if they don’t get better after some primary care…..then it is appropriate to refer to a specialist
 
bedrock said:
Agreed. I’m shocked at how few PCPs actually do primary care.

If someone presents to a pcp with a spine or peripheral joint problem, the pcp should do some primary care which means ——order PT +/- a prescription nsaid/gaba/muscle relaxer, depending on the issue.

40% of the time those patients will get better and will not need a specialist referral. And if they don’t get better after some primary care…..then it is appropriate to refer to a specialist
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Agreed, except they generally send that stuff to ortho, not “pain”. There are many pros and cons to working in an ortho group, this is one major pro.
 
bedrock said:
Agreed. I’m shocked at how few PCPs actually do primary care.

If someone presents to a pcp with a spine or peripheral joint problem, the pcp should do some primary care which means ——order PT +/- a prescription nsaid/gaba/muscle relaxer, depending on the issue.

40% of the time those patients will get better and will not need a specialist referral. And if they don’t get better after some primary care…..then it is appropriate to refer to a specialist
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i think you may be missing the big picture.

how sure are you are that you are seeing every single patient that shows up at a PCP's office with back pain?

the 3rd most common complaint patients go to their PCP for is back pain.
 
She’s had chronic cervical radic and shoulder pathology willing to get MRI and work up, ready to go to PT
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this patient is not ready for COT.

you need to have appropriate treatment before starting Chronic Opioid Therapy. if an MRI scan (or CT) has not been done, if the patient has not tried PT, i would hazard that there is insufficient evidence to commit to long term COT.


again, the issue appears to be the feeling that something has to be done, whether that is an injection or medications. Pain is vastly different from any other specialty besides psych in that it is subjective. sometimes for chronic pain, the best thing is to not do any medical intervention and to focus on why the patient is having such severe pain.

===
what do we do better than everyone else?

we should be better than anyone else at telling a patient that opioids are not appropriate. that what they are taking is dangerous, and there are alternatives to managing (not curing) chronic pain.



that, and non-labor epidurals.
 
Ducttape said:
this patient is not ready for COT.

you need to have appropriate treatment before starting Chronic Opioid Therapy. if an MRI scan (or CT) has not been done, if the patient has not tried PT, i would hazard that there is insufficient evidence to commit to long term COT.


again, the issue appears to be the feeling that something has to be done, whether that is an injection or medications. Pain is vastly different from any other specialty besides psych in that it is subjective. sometimes for chronic pain, the best thing is to not do any medical intervention and to focus on why the patient is having such severe pain.

===
what do we do better than everyone else?

we should be better than anyone else at telling a patient that opioids are not appropriate. that what they are taking is dangerous, and there are alternatives to managing (not curing) chronic pain.



that, and non-labor epidurals.
Click to expand...

If someone told me that my pain was in my head, I'd be pissed.
 
bedrock said:
Agreed. I’m shocked at how few PCPs actually do primary care.

If someone presents to a pcp with a spine or peripheral joint problem, the pcp should do some primary care which means ——order PT +/- a prescription nsaid/gaba/muscle relaxer, depending on the issue.

40% of the time those patients will get better and will not need a specialist referral. And if they don’t get better after some primary care…..then it is appropriate to refer to a specialist
Click to expand...
As with every specialty there's a lot of variety. The only times I refer to you without a decent work up and having tried a few things is a) They moved into town and were seeing a pain physician for injections and want to continue getting those or b) they demand a referral and are very resistant to anything I suggest we do first. Until my income isn't partially tied to patient satisfaction, that latter case isn't going anywhere.

I do understand that not all of my peers do this, and that's unfortunate for everyone involved
 
IMG_0890.png

Forums back at it again, now shots fired at psych!
 
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