Sounds like a really tough patient. It is too bad someone not only wrote for those medicines but decided at some point to increase the dosing.
Lobelsteve says that it works sometimes (chronic opioid for non-malignant pain) but that isn't what the data shows. If a patient on workers comp gets opioids in the first week after getting "injured" on the job, that is an independent risk factor for not working in 1 year. Opioids for chronic pain suck (sorry lobelsteve). And so I don't mind when a "needle jockey" understands that no one on a morphine dose (or equivalent dose) of ~150 day is ever better with their meds. I don't think I have ever met a patient that was on that much morphine say, "I am so happy with my pain control." So when someone sees this and say's "well I don't know what will help you and I know that opioids are changing your physiology, your personality, and making you hurt more in the end, so maybe let's try a spinal chord stimulator." I just don't see anything wrong with that. This is exactly why the polyanalgesic pain something or other consensus panel just changed their first line treatment of intrathecal medicine to ziconitide cuz opioids just don't work. A SCS just might. That is why you trial them first.
Lobelsteve, I hope you do have great success with the patients and are able to get rid of all their opioids, or at least cut them down to a vicodan once or twice a week. I think it is great if you can do that. I also agree that we hear all the time from patients that they need to get 3 shots for it to work and we are constantly re-educating people that if the first one doesn't work, we won't repeat the second one (unless they really beg us too.) They get this idea from referring physicians by the way. And that's my other point. Most "needle jockies" get their patients from referrals for a procedure. I have never seen a commercial for a pain physician for self referrals, but I may be wrong. Most patients we see in our pain clinic are anxious to get a shot because PT, acupuncture, chiropractic care, pain soup meds, have not seemed to help.
I can also see why many pain physicians don't want to manage meds. Take copro's patient for example. This was completely inappropriate to have this patient on these meds. If a surgeon did a back surgery with hardware and it was all messed up, most neurosurgeons would send the patient BACK to the neurosurgeon to fix the problem and deal with their messup. It is the same thing. Most pain physicians would NEVER let the patient get that messed up, and that seems like what most med management is - that is - the FP has screwed up so bad, now they want you to fix it. That doesn't seem right.