Managing chronic pain is becoming increasingly difficult. As Dr. Rob observes, many primary care doctors simply don’t prescribe narcotic medications.
Worse, pain specialists often won’t either, preferring to focus on procedures and non-narcotic management:
What happens when, despite my best efforts, the person is still in significant pain? Most of the time I get to an impasse like this, I send the patient to a specialist. The job of the specialist is to take care of those cases that are too difficult for me to handle. But in the case of chronic pain, there is a problem: most of the pain specialists in our town don’t prescribe any narcotics. None at all. They offer procedures and non-narcotic medications, but won’t cross the line and give pain medications.
There are multiple reasons for this, including fear of DEA prosecution, risk of a “drug-seeking” patient population, and the fact that procedures for pain pay better.
But where does that leave the patient, as well as the primary care physician who’s left to treat chronic pain without any consultant backup?
Related posts:
- Treating chronic pain with narcotics and avoiding the risk of addiction
- Should some doctors be restricted from prescribing narcotic pain medications?
- Will specialists sacrifice to pay primary care doctors? Are budget-neutral changes the only option?
- Should specialists be re-trained as primary care physicians?
- When specialists provide primary care, and why patients aren’t complaining
- Should primary care distance themselves from specialists?
- Can specialists do primary care?
{ 2 comments }
Ditto here. Too much DEA activity scrutinizing our pain specialists.
Let’s see…if I’m a pain specialist, I can:
1. Prescribe opiates in a responsible manner (doesn’t pay all that well) and due to my skewed patient population draw a DEA investigation and potentially go to jail when it turns out that one of my patients is selling his oxy or ODs. There are plenty of idiot “expert” witnesses willing to testify to the existence of a “lethal dose” of an opiate…as determined by blood levels (pure steaming BS). And after all, I’m not trained in spying. How can I know for sure what patients are doing at home?
-or-
2. Never prescribe an opiate. No DEA! And guess what, injecting patients pays great…even when there’s little symptomatic benefit.
I’m a PCP, but I can’t fault the choices pain specialists are making under these circumstances.
On the other hand, what happens around here is that hordes of “patients” go to pain clinics and get “The Holy Trinity” of Soma, Xanax, and methadone and abuse the hell out of it. Then about 3 times a year they pop into the detox units for 5-7 days of Medicaid funded detox (usually when they are out of meds )–yet the addictionologists make no effort to contact or inform the “pain management clinics” with the rationale that they are all quacks and it wouldn’t help.
Clearly it would help. They will either stop supplying the abuser, or if they don’t, the next time the patient presents for detox with a clear history of abuse, the addictionologist reports them to the appropriate authorities.
But because we don’t have the guts to police our own, the jack-booted guys are left to do it and do so very clumsily.
We need to initially presume that the opiate prescribing pain docs are tying to practice medicine and do a good job–not slam them behind their backs as quacks. That presumption requires treating them as colleagues and collaborating with them when we think we see addiciton in their patients. Then if they fail trust, we need to bite the bullet and file a complaint with the medical board. Failing to do this, we haven’t a leg to stand on in complaining about the enforcement that comes from outside the profession.
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