Just in case you’ve forgotten - I have Osteoarthritis - the deterioration of the cartilage between bones. The resultant pain has been compared to un-medicated childbirth.
After a DEA clampdown, Doc cuts me morphine to 1/3 or usual.
I complain of pain.
She orders lumbar X-Rays. Result: Continued deterioration in everything below L5.
No kidding!
The 2008 X-ray was a classic - the lower spine formed an almost-prefect question mark.
Her suggestion: try physical therapy. If I sit motionless with my left leg crossed as high as it can be crossed, the pain is almost tolerable. If you want me doing anything else, give me the drugs to get through it.
I had a pain between my ribs a few years ago. So I went to my GP and described the symptoms. She poked and prodded and I ooohed and ahhhed and winced, and she told me I had inter-costal myalgia.
Great, I thought, a diagnosis! But then some fragment of my schoolboy Latin rang a bell somewhere, and I said “Myalgia? Isn’t that Latin for pain?” Yes, it was. And then “And Costal? Doesn’t that mean to do with the ribs?” Yes again.
I looked at her with one eye. I come in here and tell you I have pain between the ribs, and you tell me I have pain between the ribs in Latin? Yes, she said.
Slight hijack: Many years ago my daughter had a few fainting episodes. On a couple of occasions she hit her head when she passed out. The school nurse asked for a doctor’s note saying she was OK to go to school. The gym teacher wanted a note to exempt her from soccer. ( As if it isn’t obvious that someone who might have a concussion should not go around hitting balls with their head. ) Anyway, the doctor checked her out and said yes, she could go to school, and no, it was not a good idea to run around in hot sun hitting a ball with her head. For a diagnosis, he wrote “postural syncope.” we know what “postural” means. We looked up syncope and found that it means “loss of consciousness.” So… she passes out and falls down. Nice. The school was happy, though.
I also agree that a pain management specialist is a good idea.
The doc’s have to go by the law because some folks abused the system. So they tell me.
The amounts that bring up the red flags are determined by politicians & insurance bean counters. I’m sure they had much independent & fair & reasonable hired experts to tell them what those numbers should be and there should be no exceptions because we are the enemy or some such. The then have to chose if they are going to do what you need or cover their ass.
Well, they won’t make any money at all nor do any good if they can’t work so guess who gets hindmost.
My self & an 108# woman get the same dosage. I’m a bit over 108 #'s. Bawahahaha
Long term pain is a PITA so to speak.
So hear we are, strolling along towards socialized medicine. I am sure it will get better, aren’t you? :rolleyes:
Actually, 6 or 7 years ago, I went to the “Pain Management” department (this is UC Davis, with a huge campus in Sacramento. These are all teaching facilities.
I go in with a real live, MRI’s and everything diagnoses.
Am assigned to a poor smuck who hadn’t slept in 3 days. His instructions were basic: determine if this patient’s pain is from muscle or bone.
Not surprisingly, he flubbed it. By then it was closing time, and the real docs left.
There was a co-pay on that visit.
I never went back.
I also have stage IV renal failure - I get appointments with Nephrology three months after asking (if lucky). They are all the same: the “Doctor” who sees me does not have a business card in the rack (plenty of space) - she is doiong her Fellowship. A high-class student.
They all go the same: she pulls up my records, fumbles about, and then calls in Dr. Dan (that is correct: “Dan” is his surname) who asks about four questions then schedules regular blood tests (CDC, BMP, Phosphorus). Even money the Fellow will not see me coming and schedule blood work so we have something to talk about.
I’m now on Medicare with a good Plan F and Drug coverage - all I pay is a $6 co-pay on the morphine ($180 retail).
No new doc is going to jump at the chance to treat a Medicare patient - especially one who goes Doc shopping.
Really? That sucks! I’m in stage 5 (maintaining a whopping 8% kidney function - whee!) and I see my guy every other month. That’s who I get my Xanax scrip from, as he understands organ failure causes anxiety and an elevated BP is not so good for someone in our situation. Yes, our visits are fairly brief - blood tests, come back a week later, discuss results, some cheerleading, referrals if necessary, and see you in 60 days - BUT he cares.
I seriously would try to find a different pain management doctor. It’s your health, your wellbeing. I have found, for myself, when I have changed doctors due to conflicts, that going in with a written “Here’s what happened and why it didn’t work” kind of list helps.
I’d suggest finding a pain management physician and/or an orthopedic doctor.
GPs are unlikely to repeatedly prescribe opiates, due to the ridiculous DEA crackdown. They risk losing their license if they run into an overzealous prosecutor.
I’d also specify that you do NOT want a student or resident, as your interactions with them have been execrable.
If your insurance covers it, go outside UC Davis, to a non-teaching facility. Residents haven’t learned about the outer ends of the bell curve, all too often.
I had to go through half a dozen doctors to get reasonable pain relief (including one who said I was “addicted” to my 5/325 percocet TID that I’d been on for 4 years. Ummm, yeah, like a diabetic is “addicted” to insulin). There are a lot of assholes in the world. A fair number of them seem to be doctors.
My doc is stuck with me My previous doc, when asked how he felt about my going over to Medicare was quite explicit - since he was my doc of record, he was stuck with me. This sounded a whole lot like: “I don’t take Medicare patients willingly”.
I doubt if he is unique. All I need is to go looking for “off-campus” treatment and have the current practitioners learn of it. This town is not large enough for the medicos to NOT know (and have opinions of) other facilities and practitioners.
The nephrology doesn’t really matter - there is nothing they can do until I hit Stage V, at which time Medicare specifies and pays for (even if you don’t have Medicare) treatment. There are drugs (can’t be prescribed yet) and transplants (not even close). All they can do is watch the blood and let me know when I hit the magic number.
Just checked my drug stash. I have enough narcotics squirreled away to have a pain-free month or two. I’ll keep them until absolutely necessary…
Bay Area? You mentioned UC Davis, so would heading West get you any options?
I know you’re in chronic pain and things flat out suck (not giving you flak, I mean this), but keep looking. I had to look from Missouri to Stanford before I found Drs who were able to work with my situation.
I’m now in Sacramento - University of California, Davis (UCD) has the largest (and highly-regarded) Med Center in town. Google Maps, “UCD Sacramento” and you’ll see the size of the place.
I don’t know if this restriction on opiates is DEA (Doc says it is) or the fact that the cut was made on my first visit as a Medicare patient.
With luck, the head of DEA is going to shoot her mouth off one too many times and be replaced with an intelligent person.
If it’s Medicare, I am thoroughly screwed.
Either way, any other doc is going to be under the same rules. Mine is probably in the crosshairs due to her habit of making sure the pain is dead. I came in with a 'script for 240 hydromorphone 4 mg (which was no longer enough) and left with 45mg time-release morphine. I suspect she was supposed to try me at minimum dosage and work up. Or she does the morphine thing so often that she can make the “opiate equivalency” calc on the spot, in her head.
Either way, she may be in for “enhanced scrutiny” from whoever.
And there is the ethical problem: if she isin trouble because she was over-generous with me, how can I desert her? If a whole bunch of her patients are getting opiates, and they all leave, her practice is ruined.
I’m going to echo the suggestion you find a different doctor for your pain management concerns, albeit for different reasons than others have mentioned. Morphine is a BAD choice in individuals with your level of Chronic Kidney disease. One of the metabolites it forms, morphine-3-glucuronide, is excreted by the kidneys, and with decreases in kidney function (a GFR of < 30 mL/min) comes accumulation of this metabolite. Given that this metabolite is neurotoxic, capable of producing myoclonus (uncontrollable jerking/twitching of muscles and/or muscle groups, usually starting in the extremities) and hyperalgesia (heightened sensitivity to nociceptive stimuli, easily confused with tolerance if the clinician isn’t aware of the phenomenon, which tends to result in dose increases when opioid-induced hyperalgesia actually responds to dose decreases), and later delirium and seizures, and does not get removed via hemodialysis
If what your doctor is saying is true about the DEA, I can understand why. According to every chronic pain guideline (I currently have 6 of them, spanning 3 countries), the goal of evidence and expert-consensus based pain management is NOT to “make sure the pain is dead” as you put it. The goal for pain management is an increase in or restoration of functionality in one or more activities of daily living. If that can’t be accomplished, based on the average size of effect of opioids versus placebo (we’ll ignore the fact that many of the studies involved were “enriched trials” for the moment), we’re looking at a reduction in pain intensity on a 0-10 scale of about 3 points (using either the “least” pain number or the “average” pain number). Which means if your average pain level is a 7, we’re looking for the opioids to drop it down to a 4, not 0.
Unfortunately, in my experience, many doctors (and pharmacists) don’t have the training in addiction medicine and haven’t taken the time to educate themselves on addiction and the risks of addiction from opioid therapy (the American Society of Addiction Medicine seems to agree with me, at least based on what I’ve read in their published textbook), and mistakenly conflate opioid dependence with opioid addiction. While the two are often linked, they don’t necessarily have to be. That said, while this very likely does NOT apply to you, it IS possible to be addicted even to the dose you listed.
usedtobe – a pain management physician will not be under the same rules as your doctor. Pain management clinics will have you sign a medication agreement, possibly submit to urinalysis drug testing, and attempt other treatments in addition to the pills. I get my meds, which are a comparatively low dose, but still controlled, monthly. I also receive other treatments that help and reduce the number of pills I need per month (from 125 to 100).
Also, UC Davis may be well-regarded, but if it isn’t working for you, it sucks.
Finally, you as a patient are NEVER stuck with a doctor. Finding a new one is tiresome, but you drive the bus.
Finally, if a doctor accepts one Medicare patient, they have to accept any Medicare patient. Federal law.
Yes, my experience and reading agrees with your statement about non-pain-management docs not understanding opioid dependence (physical) vs addiction (physical and mental/emotional).
This one doctor in question, though, was just a jerk. He fired me as a patient (:eek:), with no warning or reason, and didn’t have the cajones to tell me himself. I complained to the medical society since I’m almost the most boring patient known to man.
My then-fiance (fiancee? i can’t ever remember the guy one) was a doctor*, and both he and the pain management doctor I initially talked to at the pain management center agreed that in no way was I addicted. If I don’t take a dose, I might feel uncomfortable, but not enough to go seeking more from another doctor or illegally. And since I never needed an early fill or “lost” prescriptions…the odds were the rx wasn’t filling an emotional need. You know?
*the fiance’ was a coroner, and didn’t have a DEA number, so it’s not like ***he ***was feeding me pills.
The intended used to say that any idiot can make sure pain is gone. Throw enough drugs at pain, and it’ll go away. But making sure the pain is reduced *and *the patient is functional is another matter altogether.
Any specific state laws to the contrary notwithstanding, not actually true. All doctors are largely held to the same rules. Some states, like Ohio, may impose additional rules on pain management doctors due to the unfortunate existence of pill mills, but the extra rules aren’t all that onerous, from what I’ve read. In general, if a prescriber has a DEA#, and the appropriate sub-classifications attached to that DEA# to prescribe schedule II drugs and schedule III-V drugs, they can prescribe what they want, including off-label. Many states have intractable pain rules with additional diagnostic criteria. In Ohio, for example, if you aren’t specialized in pain management, you at least need to be specialized in the specific region of the body you are intending to treat in a patient with intractable pain in order to diagnose the condition as intractable. Once that step is done, though (say by a consult with a specialist), any GP can prescribe for the pain as long as they are documenting appropriately according to the intractable pain rule (and the patient isn’t displaying signs of a Substance Use disorder). I think. Been awhile since I read the rule since it technically doesn’t directly apply to pharmacists, though it has been used in a roundabout way against one pharmacist in at least one Ohio case against a pharmacist/pharmacy.
Then too, the DEA tends to take a lot of flak, and my experience is that prescribers and pharmacists alike are quick to link that blame to the DEA, even if it actually isn’t the DEA’s fault (it’s often the morons in the legislature who passed a stupidly worded/intentioned law).
Sadly, I’ve had the joy of dealing with several docs in pain management and even a few who specifically claim to be addiction specialists who are pretty much practicing in the opposite direction of every pain/addiction guideline/textbook/source I’ve gotten my hands on, so it is sadly not limited to just non-pain-management prescribers. I’ll also add, round where I practice, there’s actually only 1 prescriber I can name who seems to be prescribing consistently in accordance with the general principles behind the various guidelines (I’ve never seen him deviate, at least), and he’s NOT a pain specialist. He’s apparently a hard-ass, according to his patients, but they also back up that he does get results, even if those results aren’t perfect relief of pain. Most of the local pain specialists are largely not bad, though.
Yeah, I know. The DEA Red Flags are useful insofar as they serve as a good indicator that you probably need to dig deeper when they pop up in a patient, but they actually suck as definitive answers to whether or not to prescribe/dispense, but at least some practitioners seem to think their mere presence is enough to not prescribe/dispense and further treat a patient with a pain condition like the scum of the earth. :rolleyes:
It’s illegal (at least in Ohio) to prescribe a controlled substance for a family member, close friend, or someone you’re dating outside of a true emergency situation (I’ve run into exactly zero of those in my career so far) anyways, since it’s argued you can’t maintain the professional detachment necessary in those circumstances. That would be one of those laws/rules I actually don’t find stupid. Well, okay, it is, but only because it’s limited to controlled drugs, and not non-controlled drugs. If you can’t maintain professional detachment for one, you probably can’t for the other, IMO, which means you probably shouldn’t be writing for family outside of emergency circumstances.
And I wonder why some of the area prescribers don’t want to take calls from me anymore…
The intended sounds like a smart, reasonable doctor. Any chance we can clone him?