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Old 05-26-2009, 08:45 PM   #1
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Pain Management Decision - questions

After 3 foot surgeries in as many years and four years of pain, I have decided to go to a Pain Management doctor. My question is: what should I expect at my first visit? What questions will they ask? Will they run additional tests? My history below:

PTTD surgery with tendon transfer and sliding calcaneal osteotomy
Peroneal tendon repair (both)
Hardware removal
Arthroscopy w/debridement
Positive Nerve Conduction/EMG (deep peroneal nerve)

Currently taking Talwin PRN and Lyrica (night only)

I am "victim" of terrible side effects with medication so I'm really nervous. It sort of feels like "giving up" hope that the foot will ever be better. Right now my surgeon is addressing issues as they have come up and is giving me pain medication but I don't think I can bring myself to have another surgery to attempt to release the nerve. It doesn't always last and I have no way of knowing if it is nerve damage or entrapment. The neuro could determine that there is reduced nerve conduction (practically none) but the test was difficult to complete as my EDB muscle is atrophied.

any input on what to expect would be appreciated.

emmie

 
Old 05-26-2009, 10:05 PM   #2
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Re: Pain Management Decision - questions

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Originally Posted by emmie54 View Post

I have decided to go to a Pain Management doctor. My question is: what should I expect at my first visit? What questions will they ask? Will they run additional tests?
Hi Emmie--- I will try to help as much as possible. I don't know much about your type of condition, so please bear with me from that standpoint. However, I do have a great deal of experience with PM and can help from a general sense.

I'd be surprised if they will run many tests. Normally, PM Docs aren't specific experts on any one part of the body, although backs may be the exception because most PM patients are there for back issues. Since your surgeon has referred you, he is essentially saying that your condition has become "chronic" and you need long term PM care.....Something that is really out of his range as a Dr.

Your surgeon is the "expert" on your foot, and I doubt there will be much that the PM Doc can add in that regard. I was referred to my current PM Doc by my surgeon, and he has accepted me for what I am....Unable to be cured, and just manages my pain.


Quote:
I am "victim" of terrible side effects with medication so I'm really nervous. It sort of feels like "giving up" hope that the foot will ever be better.
This is where your new PM Doc can add a lot of value. While your surgeon is the expert of your foot, your PM Doc is the expert with meds, and how they interact with one another, as well as with other meds you may be taking. Many PM Docs are anethesiologists, so they are the foremost experts with meds in general.

Normally, the first appointment will cover your history, your pain, and the clinics "rules" or conditions for being a patient. You will probably be required to sign a pain contract that specifically outlines the expectations of you as patient....Things like:

- Using only one pharmacy for your meds.
- Only using the PM Doc for pain meds.
- No early refills
- No missed appointments or changing of appts forward.
- The use of urine screens.
- Outline of procedures for "treatments" such as injections and etc...may need a driver for example.
- Their philosophy on taking meds and driving.

Simply put, the pain contract outlines their expectations of you as a patient as a condition for receiving pain meds from them. By spelling out the conditions in advance, the hope is to avoid future problems. If you read enough of the posts on this board for example, you will see fairly regular posts re: many of these items. Violation of the contract is typically grounds for dismissal as a patient.

Hopefully, your surgeon recommended this Doc as someone who would be a good fit for you and more than likely keep you on some resemblance of the regimen you're on now. The number one rule in PM tends to be "if it's not broken, then don't fix it"......Meaning don't change a med regimen that is working if a patient is stabilized and the pain is under control.

You should determine pretty quickly (1 or 2 appointments) if this Doc is right for you. If not, then ask to be referred to someone else. It's very important that you feel very comfortable with this new PM Doc, because he will more than likely be your Doc for a long time. Most who end up in PM, are there for life. That's not to say that your condition may be resolved one day, but in all liklihood, your surgeon wouldn't have referred you to a PM Doc for "acute" pain.

Take care and I hope this all works out well for you. Please let me know if I can help further.

Regards,

Ex

 
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Old 05-27-2009, 09:25 PM   #3
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Re: Pain Management Decision - questions

Hello Emmie - hope you are feeling okay! I just wanted to emphasize something that Ex said about being comfortable with you new pm. I have been under pm for a little over a year and have yet to really feel comfortable. I think I am getting there, but I just think it should have happened a long time ago. In my case, I live in a small town and this is the only pm in my town. I hope everything works out at your appt!

A

 
Old 05-28-2009, 02:53 PM   #4
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Re: Pain Management Decision - questions

Thanks guys. they actually called today to make my appt. but the nurse had failed to check which doctor my surgeon prefers so I'm waiting for a call back. I have a great relationship with my surgeon and he knows I am, lets say "sensitive" to the whole pain meds issue so hopefully he will pick someone that he thinks is a good fit for me. We'll see. If not, I'm not afraid to tell him. When I went to the neuro for my nerve conduction study my surgeon had told me to discuss nerve medications with him and get his opinion on the best one for me. When I said, "I want to talk to you about medication" he snapped, "I'm NOT prescribing narcotics for you. If you are looking for that, then go to Pain Management". I was furious. I said, " I am NOT looking for narcotics. I wanted your opinion on nerve medications. I'm tryhing to take LESS narcotics, not more!" After that he settled down and acted okay. But I was SO mad! I sent my surgeon an e-mail where I ranted and raved about his treating me like a drug seeker. My doctor was so apologetic and assured me that he has never thought that. So, if any good came of that, maybe it's that he will pick someone "gentle".

I'm still scared, though!! I just feel llike my pain is not as bad as most who go to PM, it's just always there. I'm afraid of being over medicated or, at the other end of the spectrum, they won't believe I have pain EVERY day.

 
Old 05-28-2009, 03:17 PM   #5
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Re: Pain Management Decision - questions

Emmie, I hope you get a nice, gentle pain doc and can get some relief for your pain! I can't believe the nerve of that nerve guy (hahaha, couldn't help that). I suppose there are those out there who just want the drugs, but having read your story on here, I know you just want relief from everyday pain!

Good luck and keep us posted on how this new adventure with your foot progresses.

 
Old 05-28-2009, 06:48 PM   #6
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Re: Pain Management Decision - questions

Some neurosurgeons can be really crochety. I have seen 2 and both of them had a very bad bedside manner and were snappy and short. I wouldn't worry about it as it sounds like he felt bad for barking at you about not prescribing you meds for pain, since he calmed right down I am sure he felt a bit awkward and stupid. Maybe he had a bad day with another other patient who was trying to get pain meds out of him so he was extra sensitive about them. who know's but it wasn't very nice of him. What is your fear with pain medications. as I am not familiar with your situation in regards to meds.

Not all PM Dr' prescribe narcotics so I wouldn't worry that he is going to load you up or push you to take something your not comfortable with. Just be sure to let him know your concerns and worries. no one can make you take anything you don't want to take, so it will all be okay. I hope your apt goes really good and that your comfortable with your new PM DR.

Let us know how it goes and all the best to you.
SS

 
Old 05-28-2009, 08:34 PM   #7
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Re: Pain Management Decision - questions

What is your fear with pain medications. as I am not familiar with your situation in regards to meds.

I've just been so paranoid about becoming too dependent on them. Silly, I guess. It's just a control issue - I don't want meds controlling my life. I've been on pain meds for three years - fairly mild, and I only allow myself 2 a day at the most because I was afraid that if I took them all the time my doc may quit prescribing them thinking I was taking too much. but the fact is, I probably DO need to take them all the time as what I do take barely takes the edge off at times. I do have good days (rarely) where I don't need to take anything, or maybe just one at night and it's nice to not have to take anything on those days. I know in PM I'll need to follow instructions to a "T". But, I have made the decision to do this and trust the doctor to know what is best for me. It's just taken me a while to get to this point.

 
Old 05-28-2009, 11:04 PM   #8
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Re: Pain Management Decision - questions

Emmie - hopefully you will hear back from the pm with your apt date and you can get in soon. I know you said that in pm you have to follow instructions to a "T", so be sure you do that with your meds. PM Dr's think the opposite about not taking enough meds, (as scripted, of course). If you do not take them as scripted they could possibly think you do not need them and not prescribe them to you. Also, if you were to have a drug test and they not show up in your system, (because you did not take enough) they could possibly think you do no need them and stop giving them to you or that you are selling them, not that you are Like us pm patients would actually sell our meds, how funny is that!! You probably already know all this, but I just wanted to bring it up to be sure. Take care and I am sure everything will work out.

 
Old 05-29-2009, 06:52 AM   #9
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Re: Pain Management Decision - questions

Hey Emmie, good on you for telling your neuro off - I had a similar thing happen with my old pm dr (he still does all my nerve blocks etc because he's so well qualified), he called me a dr shopper because he thought I was asking for narcotics when I actually needed a script for an anti inflam in case of flare up post nerve block. It was in front of nurses and other patients (was in hosp for the block), I was so shocked that I didn't say anything except that he had completely misunderstood me and then I left without having the block. My GP rang him for me (he's the most lovely, [I]gentle[I] man) and explained. The pm sent a letter of apology that I then asked to be also forwarded to the hospital so that the nurses treating me in future wouldn't think me a dr shopper as I say the same ones all the time for continuity of care. Stuff them for their prejudices!!! And good on you for telling him, I'm sure he respects you all the more for it.

It's very difficult with pm and meds, I found this at first too. We don't have drug testing here (or at least it's not common practice with the pm's I know) but if we did, it would stress me out big time. Pmtest gave you some good advice - mine is much the same, tell them what you need (not what you want, if that makes sense) and read the fine print. Contracts also aren't common in Australia but in my opinion this can lead to confusion. On the other hand it's helpful because my pain relief has been terrible since my neck fusion last week and I saw my GP today. I explained the problem to him and he just rang my PM and he doubled 2 of my 3 doses of OC each day for a while. I like the fact that my dr can just ring him and get an answer on the spot in most cases because it makes me feel more secure - that said, in Aus pain meds are perhaps harder to get, especially BT meds. Another thing about my GP is that I can ring through when I need BT meds so at any one time I just get 20 but not longer worry when I need more than that. I used to think that because he'd write the script for 20 that was all that I was allowed to have for that month. Executor gave me some great advice regarding this and I found out from my GP that they have to write 20 only unless it's an authority - he also likes to know what's going on and knows when I'm struggling because of my calls to him regarding needing more meds. This is where a contract would be handy because I would have known this and perhaps saved myself months of BT pain and no sleep! I think that because your GP or primary care dr does all of the actual prescribing (the PM just advises for government reasons) contracts are seen as unnecessary.

Wow, that was a long paragraph! Sorry about that, I guess I'm trying to say that PM is a bit scary but the contracts that scare so many people actually can be a good thing too. It sounds like the US need to lighten up a bit (drug testing, pill counting etc each month) and Aus needs to be a bit more clear. Ah well, we can't have it all. I just hope you find someone you really click with, it makes all the difference. Good luck and keep that self respect, it really made me smile when I read your post

 
Old 05-29-2009, 05:08 PM   #10
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Re: Pain Management Decision - questions

Thanks for both of your good advice. I did get my call back and I go on June 17th. The doctor that my surgeon recommended is an anesthesiologist/pain mgmt. I know that Ex said that it makes a difference in their philosophy. I was a little relieved that it wasn't one of the rehab doctors they have in the same group. I have had SO much PT and while certain things have helped I'm not really a rehab candidate. Of course, I will try anything they think will help. I see my doctor the week before so the timing should be good. I actually could have seen the PM next week but I really wanted another visit with the OS before then.

I appreciate everyone's advice. It really helps.

 
Old 05-29-2009, 07:03 PM   #11
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Re: Pain Management Decision - questions

Quote:
Originally Posted by emmie54 View Post

The doctor that my surgeon recommended is an anesthesiologist/pain mgmt. I know that Ex said that it makes a difference in their philosophy. I was a little relieved that it wasn't one of the rehab doctors they have in the same group. I have had SO much PT and while certain things have helped I'm not really a rehab candidate.
Sounds like your surgeon has positioned you well for good PM care. I am biased, but I think anethesiologists are the best. If someone is truly "chronic" and need long term pain mgt, anethesiologists know the most about how meds work and what the best combinations are.

Hope things go well for you.

Regards,

Ex

 
Old 06-04-2009, 02:46 PM   #12
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Re: Pain Management Decision - questions

Hmmmm, this sounds familiar, Hi Emmie!!!

Dave


Quote:
Originally Posted by emmie54 View Post
After 3 foot surgeries in as many years and four years of pain, I have decided to go to a Pain Management doctor. My question is: what should I expect at my first visit? What questions will they ask? Will they run additional tests? My history below:

PTTD surgery with tendon transfer and sliding calcaneal osteotomy
Peroneal tendon repair (both)
Hardware removal
Arthroscopy w/debridement
Positive Nerve Conduction/EMG (deep peroneal nerve)

Currently taking Talwin PRN and Lyrica (night only)

I am "victim" of terrible side effects with medication so I'm really nervous. It sort of feels like "giving up" hope that the foot will ever be better. Right now my surgeon is addressing issues as they have come up and is giving me pain medication but I don't think I can bring myself to have another surgery to attempt to release the nerve. It doesn't always last and I have no way of knowing if it is nerve damage or entrapment. The neuro could determine that there is reduced nerve conduction (practically none) but the test was difficult to complete as my EDB muscle is atrophied.

any input on what to expect would be appreciated.

emmie

 
Old 06-04-2009, 02:57 PM   #13
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Re: Pain Management Decision - questions

Emmie,

You and I know each other from the PTTI forum. I also had my surgeries and am still in pain three years out from the last surgery. I've gone to two PM's so far, and the second guy is much better than the first was.
What you should bring to your first appointment is to have the operative reports from your surgeon either in hand or have them sent to the PM in advance. I like to have a copy of them anyway because I find that they can come in handy if the first doctor doesn't work out.
My first pain doctor told me (the FIRST time he saw me), "you've had extensive surgery on your feet", I said "yes I know", he said "I'd never have surgery on my feet", I said "with all due respect why do you say that?", he said "I see too many people come in for pain as a result of foot operations", I said "well I waited for nine years to have the surgery, I couldn't walk any more and was in constant pain and had pitting edema on both feet, I didn't feel like I had a choice". I should have walked out right then. The second doctor's philosophy is much better, he says that there's a difference between being addicted and dependent on medicine. He said that if you have high blood pressure you're dependent on the medication to control the blood pressure, you're in pain, so you're going to be dependent on the pain meds. It's different than being addicted to the pills. You DON'T take them to be high, you take them to be able to function, in a relatively pain free (as much as possible) way. You're still going to feel the pain, it just won't be as bad. I can't take any of the nerve medications, they zonk me out. The pain meds are fine with me (except for the constipation). They just take the edge off.

Expect to sign a contract, expect to have urine tests, expect to be called in for pill counts.

Good luck,

Dave

Last edited by dmarcus48; 06-04-2009 at 03:00 PM.

 
Old 06-04-2009, 05:47 PM   #14
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Re: Pain Management Decision - questions

Hey Dave, Yes we are "foot pain friends". I have requested my operative reports and I already have my MRI/Nerve Conduction/EMG reports. It will be interesting to read the operative reports. Actually, I don't know why I've never requested them before now, as I like to have all of my medical information on hand. I'm looking forward to the visit but still a little apprehensive.

Thanks to all.

emmie

 
Old 06-04-2009, 06:03 PM   #15
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Re: Pain Management Decision - questions

Well, it's natural to be nervous. I don't blame you one bit. I hope it works out for you, it's helped my quality of life tremendously. Good Luck!
And the operative reports are very interesting as well. I've never been good with the medical terms for the procedures, so it's nice to see it in black and white.

Last edited by dmarcus48; 06-04-2009 at 06:04 PM.

 
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