What I've decided to do is tell everyone on the phone that asks that we do not do chronic pain management. They can go to a pain center for that. Of course you will have your own patients moving into this realm with legitimate pain problems. From discussion with the Ivory Tower pain specialist at UW, I have been told that for the most part, all the pain clinic expensive procedures are useless. They are only intersted in procedures, however, because they pay big bucks. Further, the long-term treatment of pain with opioids is useless. Most patients at 10 years, now on 10 times the dose, will say their pain is just as high on the 1-10 scale as it was previously: tolerance complicated by dependence. A significant percentage end up on street heroine when the pain pills no long work. I tell patients about this FROM THE START, about the road they may be starting down. I do treat some of them, but when they want to move on to MS Contin, Roxy, etc, they won't be getting it here. I refuse to be an accessory to the problem. What to do about the back pain then? You need to get to the core of the problem. For many people it is boils down to Poor Physical Fitness. If they really want to get better, they need to become fit. Other pain problems have no solution, and you just have to live with it. Yes, that sucks, but that's life and better than being a heroine addict.
For my light weight pain patients, they are taking 3 hydrocodone per day, some taking just half a pill at night before bed and not accelerating, I have a careful program constructed similar to the UW pain programs. Any requests for increasing doses (remember, increasing the dose just builds more tolerance) that is too accelerated, means a red flag and perhaps going to a specialist. They all sign a pain agreement. When you doctor shop after signing this, it becomes a crime. The agreement says all records can be shared with law enforcement. There are is a "three legged stool" of safety: pharmacy database search, random urine drug tests, and pill counts. I do all these with the patients and document when the last stool leg was done in the chart. There is a lot of other language the DEA likes in the chart which I can post too. Overall, my chronic pain load just about stopped when I quit taking adult medicaid. When someone new calls and says they have back pain, my receptionist tells them this is not a pain clinic.
