Suboxone - NYTimes cover article 11/17/13

[314117]

http://www.nytimes.com/2013/11/17/h...bupe-can-be-savior-or-menace.html?ref=us&_r=0

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[deleted472101]

Does anyone here prescribe?

 

[Aether2000]

Prescribe for pain but not addiction

 

[101N]

Does anyone here prescribe?

Savvy addictionologists - Kolodny - argue that, even with diversion, the upsides outweigh the downsides of this drug. (1)

I obtained the waiver but I do not - yet - prescribe. I think your training and practice setting need to be air tight to do it right. Specifically, multi-provider and mulitidisciplinary. The yearly mortality for opioid addiction is purported to be 15%. This is a very high risk audience.

It's a shame that some physicians are treating this as a money making scam.

1. http://www.ncbi.nlm.nih.gov/pubmed?cmd=historysearch&querykey=7
http://www.fsmb.org/pdf/2013_model_policy_treatment_opioid_addiction.pdf
http://www.nytimes.com/2013/11/18/h...are.html?smid=tw-nytimeshealth&seid=auto&_r=0

 

[Aether2000]

I agree....it has more upside than downside. However, pain physicians are not addictionologists, lack the training of addictionologists, and by obtaining the DEA license to prescribe for addiction while prescribing opioids for pain, are creating an inherent conflict of interest. It becomes a revolving door. Here, take this oxycodone. Oh, can't control your usage, then here, take this suboxone....
This indeed can be a scam in the wrong hands, is self dealing, and may result in financial rape of a patient.

 

[101N]

by obtaining the DEA license to prescribe for addiction while prescribing opioids for pain, are creating an inherent conflict of interest.

Good lord, we have a point of agreement!

FOR THE PAIN SPECIALISTS AND OTHERS READING THESE ARTICLES: NOTE THE RECURRING THEME OF ADDICTION IN THOSE TREATED WITH OPIOIDS FOR FMS. DO NOT PRESCRIBE OPIOID FOR FMS

 

[deleted472101]

Only reason I ask is to potentially help those patients from the "old ways" without referring them to an addiction specialist. Patients may not feel comfortable going to an addiction specialist.

 

[emd123]

I agree....it has more upside than downside. However, pain physicians are not addictionologists, lack the training of addictionologists, and by obtaining the DEA license to prescribe for addiction while prescribing opioids for pain, are creating an inherent conflict of interest. It becomes a revolving door. Here, take this oxycodone. Oh, can't control your usage, then here, take this suboxone....
This indeed can be a scam in the wrong hands, is self dealing, and may result in financial rape of a patient.

Agree.

With the addiction of: there is no magic opiod that is not abusable. It doesn't exist, not even suboxone.

 

[emd123]

Good lord, we have a point of agreement!

FOR THE PAIN SPECIALISTS AND OTHERS READING THESE ARTICLES: NOTE THE RECURRING THEME OF ADDICTION IN THOSE TREATED WITH OPIOIDS FOR FMS. DO NOT PRESCRIBE OPIOID FOR FMS

Anyone can walk in and say "I hurt all over" and there's no objective test to rule it in or out. No MRI finding, no scar, no emg, no X-ray, nothing. It's 100% based on patient trust.

 

[Aether2000]

Guess psychologists must be very trusting since their diagnosis and treatment is 100% subjective.

 

[Ducttape]

Anyone can walk in and say "I hurt all over" and there's no objective test to rule it in or out. No MRI finding, no scar, no emg, no X-ray, nothing. It's 100% based on patient trust.

what in the subjective nature of pain is not somehow based on trust?

dont ever tell a patient that they dont have pain. thats an opening for a testy relationship that may lead to a lawsuit. and while we do not have any current testing to "diagnose" FMS, that doesnt mean that a clinical condition will not be found. imagine if we didnt have viral cultures/assays for meningitis. are those headache patients with viral meningitis "faking" it?


whether opioid therapy is appropriate for their pain +/- condition is a completely different question

 

[101N]

In the absence of a reliable pain marker, we need to move to evidence-based opioid prescribing for CNP.

 

[michaelrack]

Guess psychologists must be very trusting since their diagnosis and treatment is 100% subjective.

For psychologists I guess it depends on the population they treat. For psychiatrists it is about 85% subjective. There are some objective signs in psychiatry, especially in the acute presentation of psychotic and bipolar disorders. Also, don't forget eating disorders.

 

[michaelrack]

Only reason I ask is to potentially help those patients from the "old ways" without referring them to an addiction specialist. Patients may not feel comfortable going to an addiction specialist.

That is not going to be a very good defense when you are investigated by the DEA or state medical board after your patient diverts or misuses suboxone. By the way many general psychiatrists are qualified to prescribe suboxone and do prescribe it. I used to.

 

[emd123]

dont ever tell a patient that they dont have pain.

I never doubt anyone's pain. I learned that about 30,000 patients ago. I can't prove a "lack of pain" any more than the presence of "pain." But I don't treat all pain with opiates, just because someone decided:

All pain complaints with negative work ups = A constitutional right to a lifetime of opiates without condition

If 15,000 per year weren't dying from opiate/benzo ODs, then it might not be an issue, but it is 2013, not 1986.

imagine if we didnt have viral cultures/assays for meningitis. are those headache patients with viral meningitis "faking" it?

Apples to oranges.

Viral meningitis is self limited with low morbidity and mortality. When's the last time you treated viral meningitis with a lifetime of opiates?

How many people died of accidental prescription medication ODs last year?

15,000+

How many died of viral meningitis?

Estimated : <750

(75,000 cases, <1% mortality)

http://emedicine.medscape.com/article/1168529-overview#4

How many died of fibromyalgia?

Zero.


Are you suggesting we treat fibromyalgia with viral meningitis, because that would be much safer (reductio ad absurdum)?

whether opioid therapy is appropriate for their pain +/- condition is a completely different question

Yes, that's the point.

 

[emd123]

Guess psychologists must be very trusting since their diagnosis and treatment is 100% subjective.

You post that over and over again but it doesn't hold water, because you are comparing apples to apricots. Depression, anxiety, PTSD, OCD and the like aren't treated with opiates.

If psychiatrists were treating their depression patients with opiates, based on "trust" to make them "happy" I would in fact be very concerned.

But opiates were used to treat depression prior to the 1950s. Why wasn't that continued?

 

[101N]

There seems to be a consensus developing that opioids should not the final common pathway for all CNP. But,
noone here wants to take that to it's logical next step: Which CNP conditions are chronic opioids appropriate for?

We can dance around and suppose, or we can start to treat CNP like we do all other diseases.

 

[100YardDash]

Interesting article! Thx for posting it. quick question.. why are doctors who prescribe suboxone 5-14 x more likely to have been disciplined by a state medical board sometime in their career? Is it because it attracts shady doctors or because if you treat w/ suboxone, you are over scrutinized by the medical board? or a little of both? Also, I can understand how this field can be rewarding given the complexity of managing these patients. But what I don't understand is that it seems as if these docs are playing russian roulette.. meaning, I get the impression that if you follow the guidelines of prescribing suboxone to a T, but lets say patient X overdoses by mixing suboxone with a benzo (they obtained the benzo from a friend lets say), then you are liable... thats crazy! How can you be held responsible for this? thanks for the responses

 

[Ducttape]

I never doubt anyone's pain. I learned that about 30,000 patients ago. I can't prove a "lack of pain" any more than the presence of "pain." But I don't treat all pain with opiates, just because someone decided:

All pain complaints with negative work ups = A constitutional right to a lifetime of opiates without condition

If 15,000 per year weren't dying from opiate/benzo ODs, then it might not be an issue, but it is 2013, not 1986.



Apples to oranges.

Viral meningitis is self limited with low morbidity and mortality. When's the last time you treated viral meningitis with a lifetime of opiates?

How many people died of accidental prescription medication ODs last year?

15,000+

How many died of viral meningitis?

Estimated : <750

(75,000 cases, <1% mortality)

http://emedicine.medscape.com/article/1168529-overview#4

How many died of fibromyalgia?

Zero.


Are you suggesting we treat fibromyalgia with viral meningitis, because that would be much safer (reductio ad absurdum)?




Yes, that's the point.

OMG EMD, get off your holier than thou high horse and stop trying to find a fight.

where in my post did you ever come to the conclusion that opioids should be used for FMS? who the gosh darn made a single comment about "a lifetime of opiates"? because it wasnt me. oddly, you seem to acknowledge my last comment, but clearly are so deep into the muck you cant even see that the post was not about treatment, for FMS or even viral meningitis.


just because there isnt now a diagnostic test that confirms fibromyalgia (and any list of criteria is NOT a test) doesnt mean that one wont be developed. back in the day, my young padawan, viral meningitis was similar to FMS - a diagnosis of exclusion, based on suspicion of abnormal cell counts, csf chemistries, and the fact that nothing would grow out of bacterial cultures (i.e. exclusion of other diagnoses).



to simplify: Dont tell patients they dont have pain, and some day there may be a test for FMS.

thats it.
finished.
finito.
done.
kaput.

 

[Aether2000]

The post regarding psychiatrists is profoundly relevant. They prescribe controlled substances: benzodiazepines, lyrica, amphetamines, and yes, even methamphetamine for conditions that are entirely 100% subjective. Having patients take a MMPI is not objective although the psychiatrists would like you to believe they are. They may show consistent responses in certain disease states, but are not at all as objective as some of the pain docs require of their patients: aberrant MRI, anatomical deformation, etc. Yet it is perfectly acceptable in our medical society for psychiatrists to never perform a physical exam and prescribe potent controlled substances that contribute to opioid deaths in more than half the cases without a shred of objective evidence. My point is that if pain physicians prescribe controlled substances for the control of pain they are being excoriated whereas those that prescribe controlled substances for psychiatric disorders are given a complete bye. And it isn't because they are not causing death through their prescribing. Benzos contribute to death in over half the cases of opioid deaths.

As to 101's point, I believe there are conditions that are not verifiable that may or may not respond to controlled substance treatment. Just as in psychiatry, the same conundrum exists. However I don't hear psychiatrists beating any drums that controlled substances should not be made available since the treated diseases are not verifiable with objective evidence. But he does bring up an excellent question: are there any pain conditions that should absolutely not receive opioids? If so, where is the medical evidence that they do not respond at all to opioids? If that exists to any significant extent, then I agree that where there is data to support a hypothesis without any contrary data to suggest otherwise, then we must act on what evidence is available (precept of EBM). However if there is no data available to refute or confirm a hypothesis, then we move into the realm of the unknown, with clinical experience becoming the next best metric.

 

[lobelsteve]

There seems to be a consensus developing that opioids should not the final common pathway for all CNP. But,
noone here wants to take that to it's logical next step: Which CNP conditions are chronic opioids appropriate for?

We can dance around and suppose, or we can start to treat CNP like we do all other diseases.

Any pathology with objective exam and diagnostic testing with concordant history and appropriate functional deficits. Then we control for appropriate social history and support while assessment of risk and prior treatments tried. If all checks out then opiate trial with targeted functional goals can commence.

 

[emd123]

OMG EMD, get off your holier than thou high horse and stop trying to find a fight.

where in my post did you ever come to the conclusion that opioids should be used for FMS? who the gosh darn made a single comment about "a lifetime of opiates"? because it wasnt me. oddly, you seem to acknowledge my last comment, but clearly are so deep into the muck you cant even see that the post was not about treatment, for FMS or even viral meningitis.


just because there isnt now a diagnostic test that confirms fibromyalgia (and any list of criteria is NOT a test) doesnt mean that one wont be developed. back in the day, my young padawan, viral meningitis was similar to FMS - a diagnosis of exclusion, based on suspicion of abnormal cell counts, csf chemistries, and the fact that nothing would grow out of bacterial cultures (i.e. exclusion of other diagnoses).



to simplify: Dont tell patients they dont have pain, and some day there may be a test for FMS.

thats it.
finished.
finito.
done.
kaput.

Wasn't looking for a fight. Sorry, if it came off that way. I wasn't attributing the "lifetime of opiates" concept to you (or opiates for FMS) but a legacy we are all left to deal with the consequences of. (Your posts have always been reasonable.) It just gets very frustrating being caught in the middle of "pain is the 5th vital sign" and the "opiate overdose epidemic."

It's an uphill battle for all of us.

 

[101N]

Who will take this bet.

Run the following ICD-9s through a large insurer's database: 710-739, 722.52, 339, 307.81, 346.9, 729.1, 789.0, . Now
parse OUT those patients ages 21 and below and 65 and above. With the remaining cohort look only those with MEDs> 120 and publish the
% that are working.

I'll bet you the majority are not. If work is a rehabilitation goal, then in the majority of instances of CNP in working-aged adults, opioids are
harmful and ineffective.

 

[101N]

Any pathology with objective exam and diagnostic testing with concordant history and appropriate functional deficits. Then we control for appropriate social history and support while assessment of risk and prior treatments tried. If all checks out then opiate trial with targeted functional goals can commence.

For the VAST majority of CNP - LBP, HA, FMS, and chronic abdominal pain - there are no objective exam or diagnostic findings. The majority of opioid prescriptions in the US are prescribed for conditions for which there is no marker of disease.

 

[101N]

However if there is no data available to refute or confirm a hypothesis, then we move into the realm of the unknown, with clinical experience becoming the next best metric.

Ah, and to the evidence of harm?

 

[101N]

Interesting article! Thx for posting it. quick question.. why are doctors who prescribe suboxone 5-14 x more likely to have been disciplined by a state medical board sometime in their career? Is it because it attracts shady doctors or because if you treat w/ suboxone, you are over scrutinized by the medical board? or a little of both? Also, I can understand how this field can be rewarding given the complexity of managing these patients. But what I don't understand is that it seems as if these docs are playing russian roulette.. meaning, I get the impression that if you follow the guidelines of prescribing suboxone to a T, but lets say patient X overdoses by mixing suboxone with a benzo (they obtained the benzo from a friend lets say), then you are liable... thats crazy! How can you be held responsible for this? thanks for the responses

Addiction is a referral service, not primary care. If you opt to take the referral then you assume the risk. And this is a very, very risk heavy population.

I think addiction treatment is best performed in a multidisciplinary CARF or JACHO accreditation environment. The problem, of course, is that
there aren't enough of these yet. As algos has suggested, offering addiction treatment in a pain practice sets up a schizophrenic model of care. Keeping
track of who has pain vs who is now iatrogenically addicted is constant slippery slope. In my experience those physicians that offer both services inevitably tilt
toward the pill mill type.

 

[lobelsteve]

For the VAST majority of CNP - LBP, HA, FMS, and chronic abdominal pain - there are no objective exam or diagnostic findings. The majority of opioid prescriptions in the US are prescribed for conditions for which there is no marker of disease.

No guidelines support opiates for fms. None for headache but id argue 10 Norco per month is more than reasonable. Chronic abd pain is also not an opiate warranting condition. Neither are bulged disks. The rest of the back pain folks better have imaging and history to mstch reasonable rx patterns.

 

[101N]

No guidelines support opiates for fms. None for headache but id argue 10 Norco per month is more than reasonable. Chronic abd pain is also not an opiate warranting condition. Neither are bulged disks. The rest of the back pain folks better have imaging and history to mstch reasonable rx patterns.

The APS, VA, Canadian, & FSMB guidelines don't mention diagnosis as an exclusion criteria, at all.

 

[emd123]

"Trust"

If "trust" was enough we wouldn't need:


The DEA

Drug screens

PMPs

Pill counts

Controlled substance schedules

Opiate contracts

Background checks

Old records

No-opiates on-first-visit rules

Abuse resistant formulations

State medical boards

Triplicate prescription pads

Safes to lock up medications


What a mess

 

[ampaphb]

Algos: You prescribe SUBOXONE for pain? Or did u mean BUTRANS?

 

[ampaphb]

No guidelines support opiates for fms. Chronic abd pain is also not an opiate warranting condition. Neither are bulged disks. The rest of the back pain folks better have imaging and history to match reasonable rx patterns.

Steve, you are just plain wrong. I have seen enough disco positive bulges to feel perfectly comfortable prescribing opioids to elderly patients and those who perform physically demanding jobs (construction workers, offshore laborers, etc.) with multilevel bulges.

You should feel free file a complaint with my medical board. I look forward to debating the issue with you in front of the judge and jury

 

[lobelsteve]

Steve, you are just plain wrong. I have seen enough disco positive bulges to feel perfectly comfortable prescribing opioids to elderly patients and those who perform physically demanding jobs (construction workers, offshore laborers, etc.) with multilevel bulges.

You should feel free file a complaint with my medical board. I look forward to debating the issue with you in front of the judge and jury

Are these bulges attached to workers or workers comps? Or are their discos being paid bt atty liens? If you are implying that anyone with a disc bulge has pain warranting opiates then I'll accept the challenge.

 

[lobelsteve]

The APS, VA, Canadian, & FSMB guidelines don't mention diagnosis as an exclusion criteria, at all.

But all treatment guidelines for fms do not recommend opiates as part of care.

 

[Aether2000]

I prescribe both suboxone and butrans for pain. Suboxone results in blood levels of buprenorphine 10-20 times higher than butrans. Both are safer than nearly any other opioid with the possible exception of Nucynta. Insurance coverage for any of the less hazardous medications is extremely difficult however, relegating the patients to opioids that have a much higher overdose rate. But with very close monitoring and the absolute exclusion of alcohol, benzodiazepines, and polypharmacy sedating medications, opioids even in high doses may be administered safely. Lowering doses in cases of moderate to severe COPD, sedation (from any cause), hepatic disease, etc is also warranted and helps prevent overdoses. Frequent follow up, UDS, pill counts, and PMP checks also helps keep the patient population in check. Probably most importantly is the avoidance of dose escalation when there is acute exacerbation of pain, substituting other measures and telling the patient we have come as far as we will go with opioids.

Overall, as alluded to by 101 opioids at very high dosages do little more than they do at moderate to high dosages, although both regimens keep my patients functional. I have lowered the MED significantly over the past three years (Washington Agency Directors calculator) and find little change in pain perception, therefore continue to gradually lower dosages until dysfunctionality occurs.

Regarding pathologies causing pain and their objective measurement: we simply lack tools with sufficient sensitivity and specificity to consistently determine pathological-pain correlates in the vast majority of cases of pain. This is not a failure of the patient in pain but rather a failure of medical science. For instance, we all have patients with large disc herniations with neural compression on MRI with absolutely zero symptoms and we also have patients with completely normal MRI's/xrays/bone scans with severe chronic pain that renders them non-functional. Are we then to impute our inability to determine pain using objective measures to equate a lack of pathology? Or are the patients with huge disc herniations intentionally downplaying pain to avoid medical treatment? I do not believe either of these is true. The science of pain determination by interventional medicine is predicated on specific responses to procedures. If there is no response to the procedures, the interventionalist washes their hands of the patient claiming there is no objective pain source, and turfs them to psych or back to their PCP. But consider this: perhaps we lack the tools to understand all the pathologies, even focal, that may result in pain. Therefore continued pain lacking responsiveness to interventional procedures is our failure, not that of the patient. Then the real question becomes "Do we treat with medications?" If so, what meds? Are opioids specifically contraindicated in situations that we have failed to determine a specific pathology? Is the lack of high quality clinical evidence to support their use equal to a contraindication to their use if we can find a way to reduce harm? These are questions most pain physicians wrestle with, while the mindless twits simply send the patient back to their primary care doc telling them there is nothing wrong with the patient.

 

[lobelsteve]

Does anyone have a PDF of the Annals article 11/13 on Opiate Guidelines?

 

[SSdoc33]

Steve, you are just plain wrong. I have seen enough disco positive bulges to feel perfectly comfortable prescribing opioids to elderly patients and those who perform physically demanding jobs (construction workers, offshore laborers, etc.) with multilevel bulges.

You should feel free file a complaint with my medical board. I look forward to debating the issue with you in front of the judge and jury

ummmm.... why are you doing discos on elderly patients with multilevel disc bulges? i can think of one reason, and it has nothing to do with good medical care

 

[ampaphb]

Are these bulges attached to workers or workers comps? Or are their discos being paid bt atty liens? If you are implying that anyone with a disc bulge has pain warranting opiates then I'll accept the challenge.

Impressive twisting of my words, but clearly that's NOT what I said.

If you are suggesting that no workers' compensation or PI case has legitimate pain that warrants the use of opioid meds as a component of their care, then you are clearly wrong.

Also, I note you did not even bother addressing my other example: of elderly patients with multilevel bulges.

Impressive debate skills. Typical Lobelian approach - make a ridiculously overbroad statement for effect (in this case "bulging discs are not an opiate warranting condition"), and then back off the claim incrementally over several subsequent posts

 

[ampaphb]

ummmm.... why are you doing discos on elderly patients with multilevel disc bulges? i can think of one reason, and it has nothing to do with good medical care

65 year old patient with bulges at L3/4, L4/5, and L5/S1, sent by a surgeon for disco to determine which is the pain generator he should decompress? According to your challenge of my ethics, you would send the patient back without doing the disco, because you do not feel he or she is an appropriate surgical candidate?

 

[SSdoc33]

65 year old patient with bulges at L3/4, L4/5, and L5/S1, sent by a surgeon for disco to determine which is the pain generator he should decompress? According to your challenge of my ethics, you would send the patient back without doing the disco, because you do not feel he or she is an appropriate surgical candidate?

ampaphb, you are too good for this.

if the surgeon wants to "decompress", he is talking about a laminectomy. why would you need a disco for a laminectomy? if the surgeon is looking to do a multilevel fusion for multilevel disc bulges without stenosis, then you need to work with a new surgeon. since when do you "decompress" discogenic pain? if it is a decompression and fusion for stenosis, then a disco is pointless.

 

[ampaphb]

ampaphb, you are too good for this.

if the surgeon wants to "decompress", he is talking about a laminectomy. why would you need a disco for a laminectomy? if the surgeon is looking to do a multilevel fusion for multilevel disc bulges without stenosis, then you need to work with a new surgeon. since when do you "decompress" discogenic pain? if it is a decompression and fusion for stenosis, then a disco is pointless.

You're right, I misspoke. Same fact pattern, but patient is potentially to undergo discectomy and fusion. To be clear, you knew what I meant, but feel free to beat me up any time if it makes you feel like a bigger man.

 

[101N]

Now I understand your frequent defenses of discography. Charlie may have had had too much of an effect on you.

 

[lobelsteve]

You're right, I misspoke. Same fact pattern, but patient is potentially to undergo discectomy and fusion. To be clear, you knew what I meant, but feel free to beat me up any time if it makes you feel like a bigger man.

No role for discography in this patient as surgeon is going to fuse all levels. And there is no indication for fusion. Peter, you must be doing a lot of discos for surgeons. Disc bulges are normal findings on imaging in anyone over age 30. Attach those bulges to a patient with a good history and I still don't see a disco or need for opiates.

 

[SSdoc33]

You're right, I misspoke. Same fact pattern, but patient is potentially to undergo discectomy and fusion. To be clear, you knew what I meant, but feel free to beat me up any time if it makes you feel like a bigger man.

fair enough

i AM the king of pettiness and minutaie, after all

 

[ampaphb]

No role for discography in this patient as surgeon is going to fuse all levels. And there is no indication for fusion. Peter, you must be doing a lot of discos for surgeons. Disc bulges are normal findings on imaging in anyone over age 30. Attach those bulges to a patient with a good history and I still don't see a disco or need for opiates.

And therein lies our fundamental disagreement.Whether I initiate the request for discography, or comes from a surgeon, my goal is to determine which levels, if any, are pain generators.

In every case, patient has seen the surgeon, and is a potential surgical candidate. Many times, the proposed 3 level fusion becomes 1 level discectomy +/- fusion, as a result of discography. Alternatively, patients are sometimes found not to have any discs causing them pain.

If these were patients of the all knowing lobelsteve, apparently they would be told that these are simply normal findings, and thus insufficiently worrisome to be further addressed.

Alternatively, discograms could be performed by the surgeon, or another, less ethical interventionist. I would like to believe that if I perform the disco, the patient gets more accurate information, that is less biased towards what the surgeon wants.

So at the end of the day, I'd like to think but my patient benefits from doing it this way. Others may not choose to follow this course, but I don't think my approach is any less ethical than anyone else on this board.

 

[SSdoc33]

And therein lies our fundamental disagreement.Whether I initiate the request for discography, or comes from a surgeon, my goal is to determine which levels, if any, are pain generators.

In every case, patient has seen the surgeon, and is a potential surgical candidate. Many times, the proposed 3 level fusion becomes 1 level, as a result of discography. Alternatively, patients are sometimes found not to have any discs causing them pain.

If these were patients of the all knowing lobelsteve, apparently they would be told that these are simply normal findings, and thus insufficiently worrisome to be further addressed.

Alternatively, is this with Gramps could either be performed by the surgeon, or another, less ethical interventionist. I would like to believe that if I perform the disco Graham, the patient gets more accurate information, that is less biased towards what the surgeon wants.

So at the end of the day, I'd like to think but my patient benefits from doing it this way. Others may not choose to follow this course, but I don't think my approach is any less ethical than anyone else on this board.

if we are talking about only axial back pain..... why are these patients getting fused?

if we are talking about back and leg pain..... why are these patients getting fused?

if we are talking about only leg pain..... why are these patients getting fused?

fusion should be for trauma or instability -- or the rare circumstance where a multilevel laminectomy could lead to additional instability (spondy).

you can rationalize it that the patient may only be getting a 1 level fusion instead of a 3 level fusion. thats good, i guess. but, when the patients should be getting zero level fused, then it is not.

IMHO, the really the only time provocation discography is helpful is when you have a young patient with debilitating back pain with an ugly L5-S1 and a semi-ugly L4-5. then, maybe you can rule out L4-5. or, when you already have 1 level fused, and you want to rule out adjacent level disease. either way, without neural impingement, id recommend against any surgery at all.

 

[emd123]

I have lowered the MED significantly over the past three years...and find little change in pain perception...

This is a pretty profound statement.

... we simply lack tools with sufficient sensitivity and specificity to consistently determine pathological-pain correlates in the vast majority of cases of pain. This is not a failure of the patient in pain but rather a failure of medical science...

This is absolutely true. However, to the extent opiates are used in such diagnoses that have no rule-in or rule-out, is the extent to which the door is opened to those who want to use such a diagnosis to obtain opiates for illegitimate use. That doesn't mean such diagnosis don't exist. It doesn't even mean that such conditions wouldn't benefit from opiates. What it does mean that there's absolutely zero objective way in retrospect to support "legitimate medical need." Treating patients with such nebulous diagnosis with opiate isn't necessarily wrong at all, in theory, but it does create a gaping hole for anyone who wishes to abuse the system, to walk through. I suppose it comes down to the risk tolerance we all have for our practices, and how much benevolent trust one feels they can develop in a 15 minute interaction once per month with another person.

That brings us back full circle to this this: if "trust" was enough, we wouldn't even be having this discussion, there would be no opiate abuse epidemic and the forefathers of the opiate revolution would have been right.

 

[ampaphb]

if we are talking about only axial back pain..... why are these patients getting fused?

if we are talking about back and leg pain..... why are these patients getting fused?

if we are talking about only leg pain..... why are these patients getting fused?

fusion should be for trauma or instability -- or the rare circumstance where a multilevel laminectomy could lead to additional instability (spondy).

you can rationalize it that the patient may only be getting a 1 level fusion instead of a 3 level fusion. thats good, i guess. but, when the patients should be getting zero level fused, then it is not.

IMHO, the really the only time provocation discography is helpful is when you have a young patient with debilitating back pain with an ugly L5-S1 and a semi-ugly L4-5. then, maybe you can rule out L4-5. or, when you already have 1 level fused, and you want to rule out adjacent level disease. either way, without neural impingement, id recommend against any surgery at all.

See, I'm not sure when you did your spine surgery fellowship. Personally, I did one in pain. So I respect the hard work the surgeons I know did to get where they are. I refer to the more respected, most conservative spine surgeons in my community, and then defer to their knowledge, experience, and training. Perhaps you know their literature better than they do; I personally do not.

 

[lobelsteve]

And therein lies our fundamental disagreement.Whether I initiate the request for discography, or comes from a surgeon, my goal is to determine which levels, if any, are pain generators.

In every case, patient has seen the surgeon, and is a potential surgical candidate. Many times, the proposed 3 level fusion becomes 1 level discectomy +/- fusion, as a result of discography. Alternatively, patients are sometimes found not to have any discs causing them pain.

If these were patients of the all knowing lobelsteve, apparently they would be told that these are simply normal findings, and thus insufficiently worrisome to be further addressed.

Alternatively, discograms could be performed by the surgeon, or another, less ethical interventionist. I would like to believe that if I perform the disco, the patient gets more accurate information, that is less biased towards what the surgeon wants.

So at the end of the day, I'd like to think but my patient benefits from doing it this way. Others may not choose to follow this course, but I don't think my approach is any less ethical than anyone else on this board.

Sounds like gibberish to me to justify doing discography. Show me outcome data at 12 month for these patients and how it correlates with your discogram. Or has this been done in any studies in the past?

 

[SSdoc33]

See, I'm not sure when you did your spine surgery fellowship. Personally, I did one in pain. So I respect the hard work the surgeons I know did to get where they are. I refer to the more respected, most conservative spine surgeons in my community, and then defer to their knowledge, experience, and training. Perhaps you know their literature better than they do; I personally do not.

if the most conservative surgeons in your area are ordering discos right and left, i shudder at the thought of what the most aggressive ones are doing. you know, those aggressive ones also did a "spine surgery fellowship".

i dont know everything about spine surgery. guilty as charged. but if im doing a diagnostic procedure on a patient, i think its reasonable to have an idea what the surgeon is going to do with that information. otherwise, i dont do the shot

 

[101N]

See, I'm not sure when you did your spine surgery fellowship. Personally, I did one in pain. So I respect the hard work the surgeons I know did to get where they are. I refer to the more respected, most conservative spine surgeons in my community, and then defer to their knowledge, experience, and training. Perhaps you know their literature better than they do; I personally do not.

What is your zip code. I will run you through Dartmouth's benchmarking site.