Staff treatment of patients/narcotic use - in response to Requiem

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Date Joined Mar 2011
Total Posts : 1276
   Posted 8/12/2011 10:05 PM (GMT -6)   
I don't want to hijack poor Haze's thread any further, so I thought I'd start this as a new topic.

requiem_aeternam said...
We don't know all the specifics here but if there was not an overuse issue that violated the physicians directions on taking the meds, then there are several things that could be done: refer to physical therapy, use of home ultrasound, refer to a specialist, labs or xray studies, etc. There are certainly ways other than narcotics to deal with increased pain, and in some cases increases in narcotics can be ultimately more harmful. It is possible the physician's office had no more viable options to offer, however instead of telling the patient this, the staff gave curt terse and what appears to be flippant advice.
I agree completely about other options - I'm a total advocate of a multidisciplinary approach to pain management, whether it be through a formal pain management clinic, or as I do it - I have my GP, my PM, my physio, self-taught form of CBT and mindfulness training. My issue was with your general statement earlier in the piece -

requiem_aeternam said...
If there is overuse of medications (both percocet and xanax) more than prescribed, most doctors and their staff take a very dim view of this behavior and equate it to a loss of control over the medications, and will frequently tell patients to just deal with it.

Particularly the statement that staff with frequently tell patients to deal with it. I'm not trying to pick an argument. I can appreciate that you (= medical profession) do sometimes get tired and frustrated with patients, just as we get tired and frustrated sometimes with our medicos. I just feel that in ANY circumstance it's highly inappropriate for staff to tell a patient to deal with it. When I was talking earlier about maybe pain relief needing to be addressed better - it SHOULD include all those things you mentioned. They can be terribly effective, and I'm the first person to acknowledge that - I had CRPS for 6 years before I was diagnosed, and I was able to largely control my pain with physiotherapy and my own forms of distraction therapy. It's only in the last few years as it's become more aggressive and more widespread that we've had to look much at medications at all, never mind narcotics. I'm also the first to acknowledge that narcotic medication is a real pain in the proverbial, and comes with a whole range of difficulties in its use. I have gastroparesis and poor intestinal motility (preceding any narcotic medication use) that was so severe at one time it nearly cost me my life...just imagine what fun I have with narcotics... But - I'm also lucky that I have a great 'team' of specialists - used loosely because I don't know that any of them have ever met each other, but they all look after me, all communicate well with each other, and I know that I can approach any of them with anything.
CRPS since 1999, diagnosed in 2005 and since spread to full body, spasms, dystonia & contractures, gastroparesis, orthostatic hypotension,bradycardia/tachycardia, bone spurs, bursitis, carpal tunnel syndrome.

On Oxycontin/Endone, Topamax, Mobic, Magnesium, Florinef, Midodrine, Somac, Cipramil. Have a spinal cord stimulator, intrathecal pump with baclofen & bupivacaine and doing physio.

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Date Joined Dec 2007
Total Posts : 1230
   Posted 8/13/2011 2:20 AM (GMT -6)   
I have to agree with you. I have been in pain management for several different conditions, including CRPS, formerly RSD and now with my previous two back surgeries and pending third one-The only therapy suggestion that has ever been made to me that I have out and out refused to do was the insertion of a scs unit. This came after doing much research into the efficacy of scs, long term effectiveness, and most importantly from my perspective- talking to patients who had them, who had them and then had complications resulting in their removal, those who refused them and those who went through trials and went ahead, and didn't. I also spent many hours talking with a representative from one of the major companies before ultimately deciding it was not for me, at least not at this time.
I believe that pain management starts with testing, imaging studies, physical therapy, and then slowly , if necessary injections, more physical therapy, and other interventions must take place before the consideration of adding narcotics to the tool chest. I see patients come into my doctors offices all of the time, who demand narcotics, or go to the GP and demand narcotics and get highly upset when they are refused, or another non narcotic medication is suggested instead, refuse to get studies , MRI's , CT scans, emgs, evaluations with an interventional pain management doctor, or refuse referrals to physical therapy , but insist that the ONLY thing that will help is a particular narcotic and it makes me cringe. It also sets my alarm bells off, as a patient to hear those exchanges take place, especially when they become a bit heated on the new patients part.
Motorcycle accident 1992, Back problems from 92 to 2005. August 2005- early 2006- Chiropractor care
March 2006- consult with surgeon -PLIF/TLIF L4-5, spondylolysthesis, canal and foraminal stenosis, multiple herniations
Post Op Cauda Equina Syndrome
Revision August 2007- salvage op
March 2011- 2nd onset of Cauda Equina Syndrome
Needs surgery to prevent paralysis

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Date Joined Mar 2011
Total Posts : 1276
   Posted 8/13/2011 4:25 AM (GMT -6)   
requiem_aeternam said...
There are times when a patient will have reasons, valid or not, to refuse everything offered and demand narcotics only as the solution to all their ills. After repeated such demands especially with substance abuse and refusal of all diagnostics and interventions, my staff will tell thhe patient to deal with it or they are free to find another physician. I am happy for them if they can find anyone else to treat them in such cases. I have learned when prescribing opioid narcotics it is based on mutual trust that is built by verification. I have also learned the customer is not always right. They are given choices of therapies but cannot refuse everything except narctics if the therapies are affordable and medically indicated. Thank you for your valuable insight.
In that case, more than fair enough, and I thank you for your response. As I said earlier, I was taking issue with your use of the term frequently. As I also said, I'm a total advocate of multidisciplinary approach to pain management and also agree that narcotic therapy can be a minefield- particularly in situations like mrsm123 has spoken of.

But maybe it's more of an American problem? I'd never heard of any such issues, or things like routine drug testing, anything like that, until I starting using pain forums with a lot of US members, and never had any issues with either of my PM doctors on that front, any of the GPs in my clinic, or generally even in hospitals.

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Date Joined Mar 2011
Total Posts : 816
   Posted 8/13/2011 11:56 AM (GMT -6)   
Well said CRPS, as an little aside, Dr. Requiem, did you really think I thought for one minute you would agree with my conspiricy theory, as I said one example was methadone.  Thats one example, I will not mention anymore, as I said, it never occurred to me that you would agree, you are one of them.
Sorry CRPS for jacking yours, take care and hope you are feeling well. 
degenerative disc disease, fibromyalgia, osteoarthritis, neuropathy, lumbar laminectomy july 1998 no help, rechargeable neurostimulator unit low right back w/lead wires to left side and right leg unit not working just sitting there.i am 57 years young in may will turn 58. i have 2 grown daughters, 25 and 29. i have 2 grandchildren, 9 year old grandaughter and 5 yr. old grandson

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Date Joined Mar 2005
Total Posts : 1289
   Posted 8/13/2011 3:46 PM (GMT -6)   
i am by no means an expert on pain mgmt, bt have been dealing with crohn's disease for over 20 years and for the past 2 with excruciating pain as a new symptom of my far as "demanding" a certain med to deal with a condition i have 2 thoughts...1- i will take any advice a compatent doc gives and if it works great! if not let's move on to something else...2- i know my body and with all of the meds i take am nervous to start/stop different drugs all the time, so if i find something that works i tend to want to stick with that as long as possible before tyring something else...

example...i take percocets for the pain. over the past year since i started with my pm doc the effectiveness of the percs has diminished and my dosage has increase. we have tried other things such as 2 celiac plexus blocks with no success. we've talked about other meds- the patch, oxycontin etc...i research everything and made the determination that i want to stick with the percs- even if that means upping the dose form time to time...the ptch seems to have drawbacks especially in a hot climate like AZ, and oxycontin just scares the crap out of me...i did tell my doc that all of the tylenol in the percs was making me nervous, so we switched to just oxycodone...

so my point is i have no problem going in to a doc and asking for something specific. BUT i do see how docs can be quite skeptical when patients do...especially if they are new patients coming in the door for the 1st time...but docs are know supreme beings who know everything and the best thing a doc can do in that situation is ask "why" and see what the response is...from there a good conversation can ensue and the doc can make a more informed decision on that individual patient and their needs.
37 year old male living in AZ. Diagnosed with Crohns at age of 15.
Currently on 20 mg prednisone. still taking Asacol. Done with Remicade- antibody level was over 8! Waiting for scope results to see about Humira or Cimzia.
In the middle of a bad flare now for 2's been one heck of a ride!
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