Weeding out the Fakers in Pain Clinics...

[drusso]

How many hoops do you make patients jump through before you believe their pain experience is legit? Asking for a friend...

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[Agast]

I have a running conversation with the patient during their physical exam. What's their pain like in the morning, how is it when they're driving, have they tried XYZ. Touch a little on their home life and relationships, whether someone helps them with their medication management or if they're a caretaker for a sick family member. I like having a clear picture of who I'm treating and someone with "legitimate" pain will respond differently than someone who's trying to remember a script. Basically what I'm looking for is sincerity.

 

[Ducttape]

what hoops?

 

[lobelsteve]

Pain is a subjective phenomenon and is whatever the patient says it is.

The treatment of pain is dependent on several factors. Maybe you are trying to ask which patients complaining of pain warrant the use of XYZ treatments?

 

[NOSfan]

Asking for a friend...

No need to be embarrassed, my nurse will get you scheduled ASAP

 

[Disciple]

How many hoops do you make patients jump through before you believe their pain experience is legit? Asking for a friend...

I'm looking at the title of the thread.

Do you mean physical pain with heavy psychological overlay, or straight up malingering?

 

[Orin]

I find it difficult to be a pain physician without some fear of being duped and having your meds diverted to the streets, but as the others alluded to, I try to understand the nociceptive issues and the suffering issues separately. I'm not sure there's a lot of true textbook malingering cases, but I see plenty of OUD/anxiety/depression/addiction.

Nociceptive issues get treatments for analgesia.
Suffering gets treatments aimed at underlying psychiatric comorbidities and life coaching.

I spend some time discussing quality of life, sustainability, safety, etc.
I don't win all the time, but I don't want to become a cynical jerk yet.

 

[chibadriver]

Like Orin stated, I try to approach every encounter with the notion that patients don't see us because they are in pain, they see us because they are suffering. What they are suffering from is a balance of all things that feed chronic pain, addiction, mood disorders, mental illness, etc. We help where we can and identify resources for the rest.

From last year sometime: I was providing an opioid trial to a young lady with CPP while we started PT and got her ready for injection. After awhile, my nurse noticed others from the same apartment complex had scheduled appointments and started seeing me. Some got meds, some didn't, none of them were maintained longer than a month or two if they didn't adhere to the program: attending PT and counseling as prescribed, clean UDS, attending appointments. That young lady was indeed sharing her script and she and all her cronies were all eventually fired from our clinic.

What else can I do? If someone wants to go through all that BS for a little muscle relaxant or the rare opioid, I'm not sure I can do more than keep practicing in a prudent manner. idk...

 

[Laryngospasm]

At the end of the day the problem is we are not police detectives and can’t follow these people around and see what’s really going on. Humans are deceptive, manipulative, and cunning and will do anything to get what they want. For those of you who think you haven’t been duped you are dead wrong. You have. We all have. All you can do is use your judgement and try to help the people who can be helped. IVe seen a sweet old grandpa with multiple spinal surgeries who’s granddaughter was selling his meds in a hotel she worked at. You never know what’s going on. If you think you do you are arrogant and out of touch.

 

[drusso]

I'm looking at the title of the thread.

Do you mean physical pain with heavy psychological overlay, or straight up malingering?

Should it be hard or easy to access pain treatment?

 

[jonnylingo]

I know I'm preaching to the choir, but behind each of the ~15,000 Rx Opioid deaths/year is a well-intentioned (but duped) physician, NP or PA who signed off on that Rx.

Drug Overdose Death Rates | National Institute on Drug Abuse

The Centers for Disease Control and Prevention collects information on deaths involving many commonly used drugs

www.drugabuse.gov

 

[drusso]

I know I'm preaching to the choir, but behind each of the ~15,000 Rx Opioid deaths/year is a well-intentioned (but duped) physician, NP or PA who signed off on that Rx.

Drug Overdose Death Rates | National Institute on Drug Abuse

The Centers for Disease Control and Prevention collects information on deaths involving many commonly used drugs

www.drugabuse.gov

View attachment 312083

How many of those patients do you think had bonafide pain conditions versus addicts masquerading as pain patients?

 

[lobelsteve]

More importantly, it is imperative to distinguish how many of the 15000 of those folks actually had a prescription in their name.

 

[Ducttape]

More importantly, it is imperative to distinguish how many of the 15000 of those folks actually had a prescription in their name.

which is why access to these drugs should be limited to only the rare few who have a palliative condition.

or... we can do what the AMA and patient opioid advocacy groups want and allow us all to become legitimate drug dealers by prescribing for everyone.


fwiw, it should be easy to access pain treatment. but pain treatment =/= prescriptions, and especially not controlled substances.

 

[lobelsteve]

Disagree near completely with your assessment.
Choose wisely.
Retest risk frequently.
Stop when risks>benefits.

 

[Ducttape]

which is why we will never resolve opioid dependence as a public health concern in our country.

 

[deleted993114]

I find it difficult to be a pain physician without some fear of being duped and having your meds diverted to the streets, but as the others alluded to, I try to understand the nociceptive issues and the suffering issues separately. I'm not sure there's a lot of true textbook malingering cases, but I see plenty of OUD/anxiety/depression/addiction.

Nociceptive issues get treatments for analgesia.
Suffering gets treatments aimed at underlying psychiatric comorbidities and life coaching.

I spend some time discussing quality of life, sustainability, safety, etc.
I don't win all the time, but I don't want to become a cynical jerk yet.

We are trained to believe what patients tell us- that is medicine.

Thus we can and will be "duped" by patients when you are trained to trust what a patient tells you.

85% of patients presenting to a pain clinic will have depression, 90% anxiety, and 30% a somatoform disorder. Our approach tends to be focuses in an anatomical approach and often forgets these facts. Also the fact that deconditioning contributes to the vast majority of pain states.

 

[Extralong]

We are trained to believe what patients tell us- that is medicine.

Thus we can and will be "duped" by patients when you are trained to trust what a patient tells you.

85% of patients presenting to a pain clinic will have depression, 90% anxiety, and 30% a somatoform disorder. Our approach tends to be focuses in an anatomical approach and often forgets these facts. Also the fact that deconditioning contributes to the vast majority of pain states.

So true and well said; every once in a while I have to take step back and remind myself of this.

 

[Jcm800]

We are trained to believe what patients tell us- that is medicine.

Thus we can and will be "duped" by patients when you are trained to trust what a patient tells you.

85% of patients presenting to a pain clinic will have depression, 90% anxiety, and 30% a somatoform disorder. Our approach tends to be focuses in an anatomical approach and often forgets these facts. Also the fact that deconditioning contributes to the vast majority of pain states.

The lidocaine to the back with the 27 gauge needle test often reveals way more than an entire visit about psych and coping skills...

often the prep solution or blood pressure cuff can answer many important questions haha