when all the usual treatment options have failed

[ctts]

Curious to know what you tell your patients when all the usual treatment options have failed? Especially the outside of the box, alternative options, perhaps not necessarily with strong evidence support?

By usual treatments, I am thinking:
1) Non-opioid meds: Tylenol, NSAIDs, muscle relaxers, anti-depressants (e.g. duloxetine), anti-neuropathic meds (e.g. gabapentin)
2) Tramadol
3) PT, exercise
4) chiropractic
5) acupuncture
6) injections, RFA
7) surgery

And then maybe take it one step further and say they have already tried or not a candidate for the following:
1) IT pump, stimulator
2) regenerative med: PRP, stem cells
3) marijuana/CBD
4) psychiatry/psychology to address depression/anxiety
5) mindfulness, meditation, relaxation therapy

I could add more, but I think you get the idea. The patient who has tried everything, and you have exhausted all of the easier/conventional/accessible/realistic options. And maybe they are thinking, "Since there are no other options, why can't I have opioids?" If not prescribing opioids, what else do you offer these patients, if anything? Would any of you suggest more obscure and questionable treatments like low dose naltrexone? Or maybe you give them a list of suggested reading for self-help books? What do you say when you have to dig deep? Or at this point do you just say, sorry, I do not know how to help you, which inevitably causes the patient to say, "You mean I just have to suffer with this pain forever? This is no way to live!"

---

Members don't see this ad.

 

[RoloTomassi]

I don't have a problem saying I'm out of tools in my arsenal. Opioids are not the answer though. I may refer to one of my friends or Mayo clinic for second opinion. Or rheum. Not dumping, more like I don't know what I don't know, a fresh perspective may be helpful.

 

[DesertDoc16]

I struggle with the same issues.
Burn through plan A, B, C, D….. etc. and they are still in pain. I hope more people chime in, I’m curious how others approach these patients that have reached the end of the decision tree. It seems that a lot of these patients are pushed over to the “med management” arm of pain practices where they start opioids and are seen/managed by mid-levels from there on out.

 

[deleted131481]

I see this as two groups of people:

1. The first has nonspecific pain without very clearly identified pathology but likely a strong overlying psychogenic component (fibromyalgia, etc). I've tried naltexone a few times without much success. I do have a smart phrase with pain psych resources - podcast, books, websites.

2. The second group has very clear pathology supported by imaging an exam where my treatment has failed (severe stenosis, OA, etc). Rarely I may start low dose opioids (10-15 MME) or buprenorphine but I don't escalate, and only if the patient is low risk and very reasonable (old lady with severe RA, etc).

I have no hesitation in telling either group that I've done what I can and have nothing else to offer. Like above, I bring up the idea of a second opinion. Some become angry or frustrated but many are appreciative that I'm straightforward.

 

[afob100]

I have no problem referring them to the closest large academic pain clinic.

Agree that low dose oxycodone (5 q8 max) for actual pathology is reasonable and if it doesn't work, then I stop it and no further opioids.

 

[Ducttape]

move up 4 and 5 into part of your usual treatments, and get them started early in to acceptance and commitment therapy (ACT). obviously, those patients who are truly palliative (elderly>80 with non-operative spinal stenosis comes to mind) may be offered low dose opioids.


Otherwise, I tell them right at the onset that most likely there is no cure for chronic pain (barring major surgery). I also tell them that everything we do has risks and benefits, and the risks of long term opioids, even low dose, far outweigh any short term benefits that you may get for an hour or two.

if they are concrete thinking, I will tell them that I agree a pain pill could help for an hour or two, but the agony from withdrawal when they dont have the medication is far worse and lasts far longer than that benefit.


second opinions and referrals to other pain doctors are encouraged. I have nothing to hide.

and before drusso belittles ACT:

Randomized Controlled Trial of Online Acceptance and Commitment Therapy for Fibromyalgia - PubMed

Online ACT reduced FM impact relative to a TAU control condition in this randomized controlled trial. Reductions in FM impact were mediated by improvements in pain acceptance. Online ACT appears to be a promising intervention for FM.

pubmed.ncbi.nlm.nih.gov

otoh, according to some KOLs, we should stim or pump or both them all....

 

[Tramadeezy]

99% of these patients end up on opioids. Maybe not in your clinic but they will eventually find someone to prescribe. American culture is not set up to create patients who are willing to put in the work to take care of a chronic condition without a pill.

 

[drusso]

move up 4 and 5 into part of your usual treatments, and get them started early in to acceptance and commitment therapy (ACT). obviously, those patients who are truly palliative (elderly>80 with non-operative spinal stenosis comes to mind) may be offered low dose opioids.


Otherwise, I tell them right at the onset that most likely there is no cure for chronic pain (barring major surgery). I also tell them that everything we do has risks and benefits, and the risks of long term opioids, even low dose, far outweigh any short term benefits that you may get for an hour or two.

if they are concrete thinking, I will tell them that I agree a pain pill could help for an hour or two, but the agony from withdrawal when they dont have the medication is far worse and lasts far longer than that benefit.


second opinions and referrals to other pain doctors are encouraged. I have nothing to hide.

and before drusso belittles ACT:

Randomized Controlled Trial of Online Acceptance and Commitment Therapy for Fibromyalgia - PubMed

Online ACT reduced FM impact relative to a TAU control condition in this randomized controlled trial. Reductions in FM impact were mediated by improvements in pain acceptance. Online ACT appears to be a promising intervention for FM.

pubmed.ncbi.nlm.nih.gov

otoh, according to some KOLs, we should stim or pump or both them all....

How does talking and listening fix fibro--a neurologically based pain processing disorder? It doesn't fix strokes, MS, ALS, etc. It feels nice and it might alleviate some distress, but psychotherapy doesn't fix neurological problems. Psychotherapy fixes psychological problems--"I feel ashamed that I have a chronic disease no one can help me with." "I feel sad that I can't participate in important adult roles in my relationship because of my real or perceived disabilities."

All specialties reach a point where a doctor says, "You can't unboil an egg." You've got what you got. The disease won. Let's make the most of what's left over. How about an egg salad sandwich? No more omelets and souflfes for you.

Focus on function and harm reduction. This is where a common-sense approach to palliation becomes important. If low-dose opioids help them sleep or play with their kids, etc. I don't see a problem. A little CBD at night, okay. Some people come to pain clinics for hydrocodone, others for hugs.

 

[Agast]

Topical ketamine cream for neuropathic pain. Belbuca works pretty well for some people and is starting to see better coverage on Medicare plans. I've had good results with RA/lupus pain patients on Belbuca and a lot of them have stomach problems, so not swallowing another pill is appealing to them.

 

[Ferrismonk]

 

[Ducttape]

How does talking and listening fix fibro--a neurologically based pain processing disorder? It doesn't fix strokes, MS, ALS, etc. It feels nice and it might alleviate some distress, but psychotherapy doesn't fix neurological problems. Psychotherapy fixes psychological problems--"I feel ashamed that I have a chronic disease no one can help me with." "I feel sad that I can't participate in important adult roles in my relationship because of my real or perceived disabilities."

All specialties reach a point where a doctor says, "You can't unboil an egg." You've got what you got. The disease won. Let's make the most of what's left over. How about an egg salad sandwich? No more omelets and souflfes for you.

Focus on function and harm reduction. This is where a common-sense approach to palliation becomes important. If low-dose opioids help them sleep or play with their kids, etc. I don't see a problem. A little CBD at night, okay. Some people come to pain clinics for hydrocodone, others for hugs.

pain is not a neurological problem. pain is a subjective experience involving a stimuli that feels noxious. those other conditions you mentioned have a neurologic basis and damage is found. can you point to a specific neuron or group of neurons that is damaged and, even more importantly, can be corrected in fibromyalgia?

this in no way diminishes the amount of pain or disability that it causes. the end point is that it is this subjectivity that determines the amount of suffering, and people can alter their suffering, in part by advancing down ferrismonk's diagram.

thanks ferris for that image. not everyone fits in that diagram. i work at getting people to step 6 or 7. opioids hinder that progress.

----------------------------
opioids are not harm reduction. they are adding a layer of harm that is not necessary and at times dangerous.

if you havent seen patients with a problem, i could list off over 1000 patients that i have seen over the last 7 years that were harmed by "a little bit of oxy".

btw, today so far is a good day. only 2 patients this morning demanding "a little bit of oxy" for chronic non-indications. i usually average 7 requests per day...

 

[drusso]

pain is not a neurological problem. pain is a subjective experience involving a stimuli that feels noxious. those other conditions you mentioned have a neurologic basis and damage is found. can you point to a specific neuron or group of neurons that is damaged and, even more importantly, can be corrected in fibromyalgia?

this in no way diminishes the amount of pain or disability that it causes. the end point is that it is this subjectivity that determines the amount of suffering, and people can alter their suffering, in part by advancing down ferrismonk's diagram.

thanks ferris for that image. not everyone fits in that diagram. i work at getting people to step 6 or 7. opioids hinder that progress.

----------------------------
opioids are not harm reduction. they are adding a layer of harm that is not necessary and at times dangerous.

if you havent seen patients with a problem, i could list off over 1000 patients that i have seen over the last 7 years that were harmed by "a little bit of oxy".

btw, today so far is a good day. only 2 patients this morning demanding "a little bit of oxy" for chronic non-indications. i usually average 7 requests per day...

If you told me that my pain wasn't a neurological problem, I'd be pissed...

[Neural basis of pain] - PubMed

Main elements concerning the physiology of pain are described, as well as the structures of the nervous system at the origin of the central control of pain: peripheral fibres (small diameter myelinated A delta and unmyelinated C fibres); spinal ascending pathways; cerebral structures relaying...

pubmed.ncbi.nlm.nih.gov

 

[Ducttape]

Pain is a result of an unpleasant emotional experience: its various components, mainly the emotional one, may be increased or decreased considering the different characteristics of the stimulus and of the affective state of the patient, as well as the context in which this stimulus is applied.

 

[drusso]

Pain is a result of an unpleasant emotional experience: its various components, mainly the emotional one, may be increased or decreased considering the different characteristics of the stimulus and of the affective state of the patient, as well as the context in which this stimulus is applied.

That's normal/protective/adaptive pain. Not boiled egg pain.

 

[Ducttape]

but what makes boiled egg pain boiled egg pain? what makes it unique?

is it not the emotional response to the pain?



if not, then are you saying that the diagnosis is what causes a pain to get to the boiled egg stage?

 

[Ferrismonk]

If you told me that my pain wasn't a neurological problem, I'd be pissed...

[Neural basis of pain] - PubMed

Main elements concerning the physiology of pain are described, as well as the structures of the nervous system at the origin of the central control of pain: peripheral fibres (small diameter myelinated A delta and unmyelinated C fibres); spinal ascending pathways; cerebral structures relaying...

pubmed.ncbi.nlm.nih.gov

As I often tell my patients, "The brain is a big pile of nerves".

 

[lobelsteve]

How does talking and listening fix fibro--a neurologically based pain processing disorder? It doesn't fix strokes, MS, ALS, etc. It feels nice and it might alleviate some distress, but psychotherapy doesn't fix neurological problems. Psychotherapy fixes psychological problems--"I feel ashamed that I have a chronic disease no one can help me with." "I feel sad that I can't participate in important adult roles in my relationship because of my real or perceived disabilities."

All specialties reach a point where a doctor says, "You can't unboil an egg." You've got what you got. The disease won. Let's make the most of what's left over. How about an egg salad sandwich? No more omelets and souflfes for you.

Focus on function and harm reduction. This is where a common-sense approach to palliation becomes important. If low-dose opioids help them sleep or play with their kids, etc. I don't see a problem. A little CBD at night, okay. Some people come to pain clinics for hydrocodone, others for hugs.

I can send all those FMS who want opiates to you. I will continue saying no.

 

[drusso]

I can send all those FMS who want opiates to you. I will continue saying no.

I don't prescribe opioids for FMS.

 

[JelloIsJigglin]

View attachment 341410

this diagram is sweet. you think it'd be offensive if i plastered this on every wall, bathroom and chair in clinic?

serious question lol

 

[lobelsteve]

I don't prescribe opioids for FMS.

You big jerk you. What about my fibro?

 

[Orin]

You big jerk you. What about my fibro?

That sounds like delayed onset muscle soreness from all that running. Cut back to 5ks on the weekend.

 

[drusso]

You big jerk you. What about my fibro?

I'm excited about this treatment:

http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.652.9385&rep=rep1&type=pdf

 

[deleted875186]

Some people truely still believe opioids help people.

Opioid Prescribing Practices After the 2016 Release of CDC Guidelines for Opioid Prescribing

This cohort examines trends in opioid prescribing for patients who were opioid naive before and after the release of prescribing guidelines by the Centers for Disease Control and Prevention (CDC).

www.doximity.com

Quote from one of the commentors is below…. Truely sad

“One of the most useful and valuable classes of drugs in human history has been demonized to the point where doctors are afraid to prescribe it, pharmacists are afraid to dispense it, and insurrance companies are refusing to pay for it.”

 

[ctts]

Great discussion here.

1. The first has nonspecific pain without very clearly identified pathology but likely a strong overlying psychogenic component (fibromyalgia, etc). I've tried naltexone a few times without much success. I do have a smart phrase with pain psych resources - podcast, books, websites.

ragnathor, would you mind sharing your smart phrase with list of resources?

 

[ctts]

I found this article to be helpful, written by an MD about his own personal experience living with chronic pain:

Escaping the Abyss of Chronic Pain

I was thinking to try to adapt this to a handout form to give to certain patients who could use some extra help and could potentially benefit. Certainly no expectation that they would find most of it helpful, but it might just be one small subpoint that sheds some light to give them new insight into their situation or one particular practical aspect that they feel they can actually work on.

 

[Ducttape]

I don't prescribe opioids for FMS.

but... its a neurological condition.....

I'm excited about this treatment:

http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.652.9385&rep=rep1&type=pdf

2010 article. I looked in to this, set up a referral pattern with a psychiatrist who was using this for severe depression.

almost impossible to get approval. did try it on a few people, but no real benefit from the pain standpoint. let it wither away, along with iv lidocaine (never worked) and iv ketamine (never got it approved)...

 

[paindoc007]

Some people truely still believe opioids help people.

Meh, that’s an obnoxious statement. Opioids do help some people. The way you wrote that implies opioids are NEVER appropriate. Which no one here would agree to.

 

[deleted131481]

I found this article to be helpful, written by an MD about his own personal experience living with chronic pain:

Escaping the Abyss of Chronic Pain

I was thinking to try to adapt this to a handout form to give to certain patients who could use some extra help and could potentially benefit. Certainly no expectation that they would find most of it helpful, but it might just be one small subpoint that sheds some light to give them new insight into their situation or one particular practical aspect that they feel they can actually work on.

Here is my smartphrase. Full disclosure - I haven't fully vetted all below but have had them recommended. Also most patients just get annoyed when I talk about this and I can see I've had minimal traction.

Smartphrase:

Chronic Pain Resources and Reading

Chronic pain can be a debilitating condition that can affect all areas of your life. Sometimes medications and procedures do not provide adequate control. Similar to how stress can trigger a migraine headache, factors like mood, stress, anxiety, and attention can affect your pain. A number of strategies including distraction techniques, mind-body exercises, relaxation, and desensitization may help you obtain greater control of your pain. Following are websites and books that focus on some of these factors. These resources may help you better understand the science of chronic pain and help improve your condition without additional medicines or procedures. These are provided only as a resource and none of these are specifically endorsed.

Websites and books
The Pain Management Workbook: Powerful CBT and Mindfulness Skills to Take Control of Pain and Reclaim Your Life - by Rachel Zoffness. This is a book that discusses understanding the neuroscience of pain. It uses strategies including cognitive-behavior therapy (CBT) and mindfulness which evidence has show can help with chronic pain.

backincontrol.com/ - A website and book written by a spine surgeon looks at ways to help calm the nervous system in order to improve pain control.

www.pain-ed.com/ - A website managed by physical therapists that includes stories and resources for managing your pain.

www.painoutloud.com/ - Includes stories of those who deal with chronic pain

Manage Your Pain - by Michael Nicholas - This is a book looking at techniques of adapting and coping with chronic pain.

Phone apps/podcast
Mindfulness Coach - Mindfulness Coach - This is an app by the VA regarding mindfulness. There is some evidence that mindfulness may improve chronic pain and mood.

www.curablehealth.com/ - This is an app for your phone that consists of lessons 2-3 times a week. It is a paid app. It looks at psychological and emotional aspects of pain and includes audio lessons and techniques to help manage pain. See the website for details. They offer a free trial and can get a discount with the following link: getcurable.com/HCP25

'Pain Rehab' podcast: search on podcast or go to painrehabsource.com. This is hosted by a clinical psychologist and includes exercises to reduce stress and calm the nervous system.

 

[bedrock]

Curious to know what you tell your patients when all the usual treatment options have failed? Especially the outside of the box, alternative options, perhaps not necessarily with strong evidence support?

By usual treatments, I am thinking:
1) Non-opioid meds: Tylenol, NSAIDs, muscle relaxers, anti-depressants (e.g. duloxetine), anti-neuropathic meds (e.g. gabapentin)
2) Tramadol
3) PT, exercise
4) chiropractic
5) acupuncture
6) injections, RFA
7) surgery

And then maybe take it one step further and say they have already tried or not a candidate for the following:
1) IT pump, stimulator
2) regenerative med: PRP, stem cells
3) marijuana/CBD
4) psychiatry/psychology to address depression/anxiety
5) mindfulness, meditation, relaxation therapy

I could add more, but I think you get the idea. The patient who has tried everything, and you have exhausted all of the easier/conventional/accessible/realistic options. And maybe they are thinking, "Since there are no other options, why can't I have opioids?" If not prescribing opioids, what else do you offer these patients, if anything? Would any of you suggest more obscure and questionable treatments like low dose naltrexone? Or maybe you give them a list of suggested reading for self-help books? What do you say when you have to dig deep? Or at this point do you just say, sorry, I do not know how to help you, which inevitably causes the patient to say, "You mean I just have to suffer with this pain forever? This is no way to live!"

I write few chronic meds in my practice, but I do offer butrans/or oral bup to such patients if they 1- have true and significant, definable, objective pathology, not widespread pain with no source, type situations.

The patient must be working if <65, or willing to work full time if younger than 65 and I put them on bup. I never ever write any opioid, not even short term for non working patients on some kind of permanent disability, and these are always the ones that hound you for them.

 

[NJPAIN]

In life pain is mandatory but suffering is optional.

 

[painfree23]

Here is my smartphrase. Full disclosure - I haven't fully vetted all below but have had them recommended. Also most patients just get annoyed when I talk about this and I can see I've had minimal traction.

Smartphrase:

Chronic Pain Resources and Reading

Chronic pain can be a debilitating condition that can affect all areas of your life. Sometimes medications and procedures do not provide adequate control. Similar to how stress can trigger a migraine headache, factors like mood, stress, anxiety, and attention can affect your pain. A number of strategies including distraction techniques, mind-body exercises, relaxation, and desensitization may help you obtain greater control of your pain. Following are websites and books that focus on some of these factors. These resources may help you better understand the science of chronic pain and help improve your condition without additional medicines or procedures. These are provided only as a resource and none of these are specifically endorsed.

Websites and books
The Pain Management Workbook: Powerful CBT and Mindfulness Skills to Take Control of Pain and Reclaim Your Life - by Rachel Zoffness. This is a book that discusses understanding the neuroscience of pain. It uses strategies including cognitive-behavior therapy (CBT) and mindfulness which evidence has show can help with chronic pain.

backincontrol.com/ - A website and book written by a spine surgeon looks at ways to help calm the nervous system in order to improve pain control.

www.pain-ed.com/ - A website managed by physical therapists that includes stories and resources for managing your pain.

www.painoutloud.com/ - Includes stories of those who deal with chronic pain

Manage Your Pain - by Michael Nicholas - This is a book looking at techniques of adapting and coping with chronic pain.

Phone apps/podcast
Mindfulness Coach - Mindfulness Coach - This is an app by the VA regarding mindfulness. There is some evidence that mindfulness may improve chronic pain and mood.

www.curablehealth.com/ - This is an app for your phone that consists of lessons 2-3 times a week. It is a paid app. It looks at psychological and emotional aspects of pain and includes audio lessons and techniques to help manage pain. See the website for details. They offer a free trial and can get a discount with the following link: getcurable.com/HCP25

'Pain Rehab' podcast: search on podcast or go to painrehabsource.com. This is hosted by a clinical psychologist and includes exercises to reduce stress and calm the nervous system.

Oh nice!

 

[Multimodal]

Here is my smartphrase. Full disclosure - I haven't fully vetted all below but have had them recommended. Also most patients just get annoyed when I talk about this and I can see I've had minimal traction.

Smartphrase:

Chronic Pain Resources and Reading

Chronic pain can be a debilitating condition that can affect all areas of your life. Sometimes medications and procedures do not provide adequate control. Similar to how stress can trigger a migraine headache, factors like mood, stress, anxiety, and attention can affect your pain. A number of strategies including distraction techniques, mind-body exercises, relaxation, and desensitization may help you obtain greater control of your pain. Following are websites and books that focus on some of these factors. These resources may help you better understand the science of chronic pain and help improve your condition without additional medicines or procedures. These are provided only as a resource and none of these are specifically endorsed.

Websites and books
The Pain Management Workbook: Powerful CBT and Mindfulness Skills to Take Control of Pain and Reclaim Your Life - by Rachel Zoffness. This is a book that discusses understanding the neuroscience of pain. It uses strategies including cognitive-behavior therapy (CBT) and mindfulness which evidence has show can help with chronic pain.

backincontrol.com/ - A website and book written by a spine surgeon looks at ways to help calm the nervous system in order to improve pain control.

www.pain-ed.com/ - A website managed by physical therapists that includes stories and resources for managing your pain.

www.painoutloud.com/ - Includes stories of those who deal with chronic pain

Manage Your Pain - by Michael Nicholas - This is a book looking at techniques of adapting and coping with chronic pain.

Phone apps/podcast
Mindfulness Coach - Mindfulness Coach - This is an app by the VA regarding mindfulness. There is some evidence that mindfulness may improve chronic pain and mood.

www.curablehealth.com/ - This is an app for your phone that consists of lessons 2-3 times a week. It is a paid app. It looks at psychological and emotional aspects of pain and includes audio lessons and techniques to help manage pain. See the website for details. They offer a free trial and can get a discount with the following link: getcurable.com/HCP25

'Pain Rehab' podcast: search on podcast or go to painrehabsource.com. This is hosted by a clinical psychologist and includes exercises to reduce stress and calm the nervous system.

this is great. thank you!