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Primary Care or Pain Management Dr.


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Old 10-21-2012, 06:49 PM   #1
Isotope
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Primary Care or Pain Management Dr.

Primary care Vs. Pain Management

As I was wading through my medical records, an actual pain management contract between me and my Primary care Physician signed 08/2011 appeared. I guess it has been expired for a while, I have no memory of of it at all, don't recall signing one. It is a pretty bare bone affair too. It basically tells me that I need to get my pain meds from only one doctor, PCP, and to use my same old Mom and Pop pharmacy as my sole pharmacy for pain scripts. great, we've been doing that all on our own. I don't think my PCP's practice is very fond of these contracts, they get signed and are promptly forgotten. I had never even read mine until now, today, and I ran across a very interesting passage.

It says:

"Primary Care Physicians are the most appropriate resource for providing care for patients with chronic pain. Pain Physicians often have an interest in invasive procedures and may not address the multiple issues that lead to intolerance of chronic pain."

Poorly written, yes. It goes on to say:

"Pain specialists should be used as consultants. Primary care Physicians should have knowledge of medication management for chronic non-malignant pain and should be the physician in charge to coordinate medications, encourage the patient, and provide referrals for supportive therapies. After a thorough history and physical, the Primary Care Physician should assess the psychiatric history, the disability level and the social and work environment."

I would be interested in some opinions on this subject. Some here are cared for in clinics by a Pain Management Physician (PMP), and some are cared for by their Primary Care Physician (PCP).

Is this merely a patient preference issue? Who should be in charge of what -and when? Does the left hand know what the right hand is doing, and what if they don't agree?


Iso~

Last edited by Isotope; 10-21-2012 at 06:51 PM.

 
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Old 10-22-2012, 12:36 PM   #2
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Re: Primary Care or Pain Management Dr.

OK, will answer it to you since I went through same dilemma some time ago.
I used to see my PM in NYC every 3 month. Than rules and regulations changed and it had to be every month. He understood
that it expensive and time consuming to see him every month and offered to see him 1x3 month, but to see my GP every month for refills.

My GP is an excellent and knowledgeable Dr. When I approached him with my issue, he honestly told me the following: "I can do it every month, no problem here but I will not be helpful to someone like you. Yes, I can Rx your prescriptions, but I am not trained in any opioid therapy, I don't go for quarterly trainings PM go, I don't read and do research on this matter. I can Rx it for someone who needs some short term opioid after tooth extraction or mild surgery, but for someone with such serous issues, you need someone really knowledgeable. I would like you to come every month and leave your co-pay in my office, but I am a Dr not a businessman".

He said due to tolerance people need their drugs to be changed (this is so true), doses need to be adjusted- this is all PM's job, not a GP. I love him for his honesty; he said that if any GP tells you that they can manage someone with chronic issue on opiates the right way - they are lying. They are not trained, they can't be helpful to you and worse, they may harm you by not giving what you need on time.

I wouldn't know the answer to your question if this wouldn't happened to me in January 2012 when they had to change their rules.

I also called my insurance and asked them who charges more for their app in my case: GP or PM DR. Of course PM DR charges more; they told me though I can use either or but PM is the answer for me since GP can't treat chronic patients who on opioids, PM is my best shot.
Hey, if the willing to pay and be honest about what is better for me - let me have someone who knows more.

Hope this helps
Moldova

 
Old 10-22-2012, 06:44 PM   #3
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Re: Primary Care or Pain Management Dr.

For me my primary care Dr. is the only answer. I saw a PM Dr. for three years and with the exception of the first 72 hours after an epidural I was never ever prescribed an opiate. Not after I had horrific mental problems from both neurontin and lyrica plus serious swelling in my feet and hands to the point where I could not wear shoes or move my fingers, not after I had three different anti-depressants cause my blood pressure to go sky high and make me tachacardic, not even after the last anti-depressant put me in the hospital for two days while they tried to get my blood pressure and heart rate back under control. The only option the PM Dr. gave me at that point was to have yet another round of epidural injections even though I react very badly to steroids, I get a reaction where the steroid crystalizes at the injection point causing much much worse pain than I started with for the first 48-72 hours. For three years I had at least one, usually two series of three steroid injections per year, plus endless series of trigger point injections, sometimes as many as 5-10 different sites in one appointment, plus near the end a series of intercostal (between the ribs) nerve blocks at four levels. Not a single one of those injections helped once the initial numbing medication wore off. But at that in point in time, if they had told me to stand on my head for three days I probably would have tried it.

That PM group does not permit prescription of opiates to anyone who does not have cancer. That PM group controls all the hospital based clinics in the two state metro area except the university hospital, which also does not prescribe opiates. There are a few private, very expensive non-hospital based clinics across the state line, but they are not on my insurance, and they do not accept cash patients.

This leaves me with getting treatment from my primary care Dr. It's either that or no treatment at all. Because I am allergic to NSAIDS opiates are about the only choice left. I see a massage therapist weekly for myofascial release therapy, rarely go anywhere without an ice pack, and take my meds as prescribed. Is it the very best situation? No, but it's what I've got to work with.

Tigg.

 
Old 10-22-2012, 08:42 PM   #4
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Re: Primary Care or Pain Management Dr.

I think this is so region and doctor specific...in some cases all the local PM doctors are only needle jockeys and therefore the PCP may be the best option the patient has who doesn't respond to those treatments. If however we are talking about a good PM doctor who uses a variety of treatments based on what is best for the patient, then yes the patient is probably better off there. In response to that wording from the contract from your PCP, it sounds like they have had some bad personal experience with PM doctors.

I spent a few years seeing neurologists for my chronic headache (I was actually one one of the lucky ones and got 20 Percocet a month). Once I moved here I was pretty sick of it all and just saw a primary doctor, then consulted with a neuro. After awhile the neuro suggested I go on daily opiates, and asked my PCP to prescribe. He agreed and we did that for a couple years. However, he wouldn't change or up my meds and I had become tolerant. At one point I had a hard time recognizing I was getting any significant relief, but I knew it was still something.

I asked to be referred to a PM doctor and he said he didn't know of any good ones. Through my own trial and error (4 interviews), I finally found one who wasn't opposed to my current opiate dose and agreed to see what we could do. Its been great to finally have a doctor who understands the issues that come with chronic pain managed with opiates...in addition to tolerance, they have screened me for underlying sleep problems, psych issues, recommended alternative therapies, tried 2 new types of nerve blocks, increased and changed my long acting med, gave me a rescue med, tried a few misc treatments.

We're working on submitting a nerve stim trial pre auth. I hope next my breakthrough med can be updated since I've been on the same med/dose for over 3 years now and its quite unhelpful. I wish I had started seeing him years ago. Although I'm not sure he would have used Methadone as a first line opiate (which oddly enough was a very good thing for me as now I've tried all the others and ended up back on it). I agree most PCPs don't have the training they need to prescribe opiates, and often over or under prescribe, or prescribe too early (acute vs. chronic pain).

However, if there isn't a PM doc available, its better than nothing. I have heard that with the recent atmosphere some specialists (non pain) that used to prescribe pain meds for their patients (rheumatologist or orthopedic for example) are now not willing, and may refer to a PCP as they may not be aware of a PM doc to refer to. Many PM clinics have long wait times, require a referral (not everyone's doctor wants them to go to one), or even don't take insurance. Best wishes.
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Old 10-22-2012, 09:23 PM   #5
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Re: Primary Care or Pain Management Dr.

Thanks for the input you guys.


I do think that this is all is highly dependent on the complexity of a particular patient's case and the amount of time and intervention needed.

So, in a complex case I think the patient would need to consult with both the PCP, and the PMP, and perhaps all three would need to have a conference call. For most of us, we've found the general recipe that works for us and we just need refills and occasional tweaks or rotations, and for that duty I feel my PCP is fully qualified and up to the task. Hi did tell me that Pain Medicine is a large part of his Continuing Education protocol so that made me feel a bit more confident.

I don't think I'm a difficult case at all, I don't have illicit drug use added to the mix, my other organ systems are good, and I've never called for an early refill. So, I see no reason to put myself under the heavy thumb of a guy (or gal) who is likely quite jaded and burned out by the demands of the difficult patient. They could even get as nasty as GI Docs if they've been at it for 20 or 30 years. I imagine falling out the window of my GI Docs exam room and hearing the tink*tink*tink of an Aspirin rolling toward my broken body...


"Don't you dare ask for more.... Narcotics are very addictive you know Mr. Iso!".


"Gee Thanks Doc. I wouldn't want to become addicted, oh what a horrible thing that would be, Why is my leg pointing the wrong way? Oh I can think of something more horrible. I'll just become a GI Doc like you!".


Iso~

 
Old 10-23-2012, 12:32 PM   #6
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Re: Primary Care or Pain Management Dr.

Iso,
I tend to disagree with the idea that a PCP is the best person to manage chronic pain patients, oversee and coordinate or make referrals , yes, but to treat chronic pain, no, I don't believe that a PCP is the best option, unless there are no pain management physicians in the area.
Pain management doctors are highly specialized, and most of them are usually well versed in all of the modalities of treating pain. The updates to the protocals , the new rules implemented by the DEA, are better managed by having your pain management doctor oversee your care if it is a possibility in your area.
Treatments for pain can vary and are changing constantly and that is where many of the primary care physicians are out of their league in being able to offer the latest technology or treatment protocals since they are not trained, even with attending updates online or CEU's programs.
Yes, your PCP should be kept in the loop, receiving updates from each physician you see, surgeon's, pain management, gastric doctors, or any other specialty physician that you see, and they should be knowledgable about the medical conditions of their patient but it does not mean that they are the best option when it comes to treating all conditions. General practioner means general - overall health, but just like you wouldn't allow a podiatrist to treat migraines, you don't allow a GP to treat chronic pain. You see the right doctor for the right condition- which offers the patient the best options available for successful outcomes..
Just my two cents.
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Old 10-23-2012, 07:48 PM   #7
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Re: Primary Care or Pain Management Dr.

I tend to agree with back. (). After my back broke and my surgeon informed me that I would live in "some degree of pain the rest of my life" he told me that he wasn't qualified to prescribe continous pain meds. He would be willing to continue to do so for some months, but I did need to see a PM. I am thankful that he was at least honest about that.

My PM is on call for me 24/7. He has told me that if I have an issue and it is after hours, they will find him and he will answer me. He encourages me to email him if I have problems, and he either returns a message to me or he has his PA (whom I adore) call me.

I see my PM every three months now that I am stable. I get three months of scripts that are post dated. I am told that if I have problem with the scripts during the months I am to call.

My PM offers me a variety of modalities to help control my pain. When he feels that we need change things he usually offers me a choice. I can also tell you that he will chastise me when he feels that I had done somehting stupid-such as waiting too long to call, letting pain get ahead of me...he tells me that he has more troubl with me getting to take my meds... But I can honestly say that I have never felt so "taken care" of as I do with this man.
Having chronic pain is difficult enough as we all know. Having someone who specializes in what I need to contro my pain is my preference.

My PCP is wholeheartedly in favor of me seeing my PM. He told me he doesn't have enough background to adequately prescribe opiates for me. That was answer enough for me-and I adore my PCP also.

I think that this will turn out to be a personal thing. If you have a PCP that is proficient in pm, then you are lucky. If you have a good PM, you are one of the blessed.

May we all find who we need to control our pain.



 
Old 10-24-2012, 03:00 PM   #8
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Re: Primary Care or Pain Management Dr.

I agree ibakeandpray. If you can find a great pain mgt doc, I have, that is the best. My doc is just like the above.

 
Old 10-24-2012, 03:28 PM   #9
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Re: Primary Care or Pain Management Dr.

Imho, be so grateful if you can be cared for by a dr who cares that your hurting, is not just trying to make money, and doesnt give you a urine test every month. If your pcp needs some help in treating you & sends you to PM for injs or advice & then you can come back to your pcp, thank heavens you are a very blessed person!

 
Old 10-24-2012, 04:43 PM   #10
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Re: Primary Care or Pain Management Dr.

Quote:
Originally Posted by gmak View Post
Imho, be so grateful if you can be cared for by a dr who cares that your hurting, is not just trying to make money, and doesnt give you a urine test every month. If your pcp needs some help in treating you & sends you to PM for injs or advice & then you can come back to your pcp, thank heavens you are a very blessed person!
There are good PMs out there. Hard to find but dr asks me every time if I have enough roxicondone and stresses not to live in unbearable pain. Says call anytime. I am very blessed. Keep searching and you will find one.

Btw, the urine tests are making sure you r taking the meds.

 
Old 10-24-2012, 06:25 PM   #11
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Re: Primary Care or Pain Management Dr.

There are not only good PM doctors out there, that care about their patients but there are great ones..it does take effort on the part of the patient too, to be willing to give all of the suggestions due consideration and effort , and to be willing to try other types of meds aside from the traditional pain meds, but they are there and they are more than willing to work with their patient, once you are established with them and show them that you are going to follow the rules.
I have only been drug screened twice in more than 7 years with my PM doctor, and to me, that is far from excessively testing but even if it had been monthly in the beginning, I would have been okay with it because I was willing to follow his guidelines and build the relationship that we have today....and that takes time on both sides.
If a new patient shows up, he treats them with dignity and respect but doesn't immediately prescribe pain medications in the traditional form- opiates right away with few exceptions..the idea that less is more when it comes to the long term picture of treating chronic pain holds especially true. It is far better to be able to treat the pain with non traditional meds in the beginning, and then as time proceeds, add opiates if necessary so that there are still tools left in the toolbox as the years progress than it is to jump right into the heavy hitters of pain meds and then be left with nothing and little room to grow in the next decade.......
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Old 10-29-2012, 10:21 AM   #12
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Re: Primary Care or Pain Management Dr.

I disagree that GP's are even close to being as qualified to PM docs. That little note about Primary care docs being the best to serve CP patients is completely self serving. In your own words that contract carries so little weight that you didn't even remeber signing it. GP's dont have any additional training in treating CP and often only a multi faceted aproach to treatng pain can bring appropriate relief. My PM group consists of a neurologist , an anesthesiologist and a Physiatrist and a psychologist on staff. I have been seen by them alll, and they are all Board certified in PM within their specialty. I have an implanted pump. A GP would never even go their.

He is basically saying the only way to treat pain is with the medication he learned about from the reps that come and push their products and nobody benefits from interventional procedures, Total BS. Just for example, My wife was able to reduce her pain med cunsumption by 2/3rds when nemanda was introduced and they started using botox on her neck, shoulders and head in conjunction with doing an occipital block every 12 weeks. Those apts cost us 120 bucks. Money well spent and cheaper than the amount of meds she was able to reduce. How many GP's use Botox to treat CP, How many are qualified to any interventional procedures whether they work or not. I have never beenn forced to try anything, I tried things because I was in pain and hoped they would help, if they didn't help we moved on. The anesthesioogist is also a BC general surgeon and does the trials himself and the implants and had hospital privlidges at 4 local hospitals. Now a days most GP's dont even have hospital privlidges, instead they use a doc called a hospitalst, usually an internal medicine doc to cooridinate specialized care when you are hopitilized.

What a bunch a self serving garbage, what additional training does this GP have asidee from maybe taking a weekend seminar in the carribean sponsered by one of the drug manufacturers that wants more of their med prescribed.

IF you have a bad heart you see a cardiologist, If you have cancer you see an oncologist,If you have a blood disorder you see a hemotologologist. How is CP any different or any easier to treat that you dont need someone that spent years training and solely practicing their specilaty. Just because a GP is willing to write the scripts, doesn't mean he is qualified to treat any complex disorder aside from strep throat and bronchitis. I haven't even seen my GP in 3 years. My PM group and all my specilaist have complete computer access to all my other specialists notes and treatment plans from cardiology to hemotology and endocrinology. Each specialist knows every med I take from every doc and every medical procedure that has ever been done.

Hogwash. Sadly if you are in an HMO you GP can prevent you from seeing any specialist he wants by simply refusing a referral. To much power for too little education and experience. JMO
Good luck Dave

 
Old 10-29-2012, 01:14 PM   #13
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Re: Primary Care or Pain Management Dr.

Shoreline,
thank you for excellent job explaining your opinion about difference in between GP and PM Drs. I can't agree with you more.
I may have my doubts too if I wouldnt talk about this matter with my wonderful and very honest GP, who is a director of department at local Hospital, Harvard trained Dr.
Very honestly he explained to me that he can write Rx for opioids but this will be it. Internists dont have PM training, no way he knows pain mgmt the way trained Pm Drs know. Dont forget that many PM are Anesthesiologists which is another training in managing pain.
He told me that if I decide to get Rx from him, I need to bring a paper from my PM about the doses I need and if i need any changes in drugs or doses, I must go to PM. What does it tell you?
Maybe dishonest GP who need more patients may tell some of his patients that this is the same thing. Don't believe in it.

Thank you once again.
Moldova

 
Old 11-02-2012, 11:45 AM   #14
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Re: Primary Care or Pain Management Dr.

Dear Moldova, As you know I have severe AA. I saw the same PM&R ( physiatrist) for 12 yrs. He stopped seeing pain patients. He & my neurosurgeon BOTH said no more back surgeries. Went to 3 neurosurgeons that wouldnt touch me & said seek pain mgmt. I saw PM 1st visit. He wont look @ MRI disc because he says it messes up his computer. He gave me the fentanyl patch i have been on for 12 yrs & msir 30mg 3◊aday. Monthly urine tox screen, they sent out of network for my insurance. $2500,i owe $2475 & this will be every month. Plus, due to AA, I had to self-cath in drs office bathroom.GROSS! This too monthly. He ordered SI joint injs the next week. And,ordered a new TENS ehen I told him not to. I have 4, & 2 have never been out of box. Also, took my picture, refused soma & seemed to know AA.
Next visit, proclaimed that 90 mg of morphine was too much."What was I thinking?" He had no chart on me with him, then said in 2 weeks I MUST decide to get SCS or go to drug rehab & stop all opoids for 6 weeks then get morphine pump..both/ either by anesthesiologist not neurosurgeon. Gave me 15mg msir 3 times a day & scheduled epi steroids for next week. He showed me on model exactly where he eas going to inject.Moldova, it is EXACTLY where my spinal cord is tethered or stuck to my dura! Plus, BOTH of these surgeries require cutting into dura. SCS- two 3 inch incisions & morphine
pump- one 6 inch & one 1 inch incision.
So, I call my PM&R(physiatrist) that I saw for 12 years & told them that dr wants to do surgery. My dr of 12 yrs calls me and says " No surgeries, come for appt in 2 days". I go see him, he agreed to take me back as his patient. Gave me fentanyl patch same as for 12 years & time- released morphine(Avinza) 90 mg every 24 hours. No breakthru. No soma. But, no urine tests or epi steroids or surgeries. Dearest Moldova, you have AA, & I feel a kinship with you. So, your advice is priceless to me. What do I do about the PM dr? What do I do? Say? What if my dr bellies up again? Would that PM see me again? I had a very hard time finding him. But all the costs, caths, surgeries? It feels like deliverance to have my old dr back. I have been seen by neurosurgeons in Texas medical center. HUGE! The best in whole of texas & surrounding states. Like M.D Anderson, St. LUKES! Baylor, Methodist, Hermann hospitals to name 5 out of 50! This PM is not in Med center, but near my home.
Please advice me. I HOPE this post finds you doing better today! Thank you angel friend, gmak

 
Old 11-02-2012, 12:04 PM   #15
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Re: Primary Care or Pain Management Dr.

My pcp told me to go see a pain specialist, because he could not prescribe me the meds that I needed. He said that the feds would take his license for the amount, and type of drug I needed. It all just seems ridiculous to me that doctors can't do their job without the threat of losing their license or worse.

 
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