#pillpusher #injectionpimp #stimwhore ???

[drusso]

Taking inspiration from #balancetonporc and #MeeToo, should the pain community start naming names?

Is it time to start Dox-ing the hell out of folks not following CDC guidelines, performing series of three's, and stimming for axial non-specific low back pain?

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[gdub25]

I've wondered this myself. Should we police our peers? Or better terminology would be "hold them accountable". Many will argue against the CDC guidelines saying they are not based on medical evidence, other will argue back that neither is prescribing opioids in the first place. For nonspecific axial back pain, if other modalities have failed and patient is reasonable Nevro has good enough evidence that's many think it's reasonable to try. Certainly safer than starting opioids.

At the end of the day I say yes, we should hold each other accountable. Large "pain practice" down the road from us consists of two family Med docs and 3 or 4 midlevels. Openly admit the average patient in their practice is well over 100 MEQ, and they have an anesthesiologist with no formal pain training who was doing injections for them a day a week. They offered stim to some patients but are 100% loyal to medtronic and never consider looking at other SCS companies despite the recent studies showing clear benefit. They don't seem to stay on the forefront of what's new in pain treatments and from the outside it appears as though they are posing as "pain doctors", writing lots of scripts and drug screening every patient every visit. This is what makes me want to call these doctors out. They aren't doing anything illegal but I do believe they are misleading patients. People walk in there and probably aren't treated with the same evidence based treatments many of us board certified guys would offer. They think that opioids and being on lifelong "pain management" is their only option.

 

[kstarm]

I have struggled with this question as well. As I work doing inpatient pain I see a number of patients in the hospital for opioid related complications and end up calling the prescribing providers which are frequently from the same area pain management groups. How they can actually sign these scripts in these patients is beyond me. I have come very close to placing formal complaints to the board for a provider that is notoriously outside of recommend prescribing guidelines. However Pain is a small community and if word gets out that you are placing complaints it may affect future job prospects. Also, I have had the case where I thought the regimen was outrageous and was going to call the prescriber and consider further action, only to find out on further chart review the patient had weaned about 50% of his medications over the last two years.

 

[hyperalgesia]

I don't think we should name names. The best thing we can do for our profession is to not fall into the ethics compromise trap, ourselves. We can set an example for others.

There's nothing wrong with pointing out that Dr. X is not practicing standard of care pain medicine but if we go on a mission to hunt down these people, it could backfire and make our field look bad.

When I hear about an oncologist who commits Medicare fraud, I don't look down on all oncologists. I just assume this was a bad apple. But if a whole bunch of oncologists brought to my attention how much fraud goes on, I would think less of the field.

 

[NJPAIN]

I have struggled with this question as well. As I work doing inpatient pain I see a number of patients in the hospital for opioid related complications and end up calling the prescribing providers which are frequently from the same area pain management groups. How they can actually sign these scripts in these patients is beyond me. I have come very close to placing formal complaints to the board for a provider that is notoriously outside of recommend prescribing guidelines. However Pain is a small community and if word gets out that you are placing complaints it may affect future job prospects. Also, I have had the case where I thought the regimen was outrageous and was going to call the prescriber and consider further action, only to find out on further chart review the patient had weaned about 50% of his medications over the last two years.

What is generally the scenario in which you are called in? Overdose? Patient on COT has injury/surgery and "requires" large-animal veterinary doses of opioids that no one is comfortable with?
What is the hospitalist's/hospital's expectation of you in this case?
In my mind there is NOTHING worse than doing inpatient chronic pain consults in the hospital setting. Having done them as a fellow I know that they are an exercise in futility and a move to make you do someone else's dirty work. I had occasion to have lunch with the hospitalists at my local hospital last week. The first thing they wanted to know was would I be willing to see inpatient consults. Then they told me that they manage the perioperative care of all of the surgical patients including postoperative analgesia. They see tons of patients receiving COT who come in for surgery and require absurd doses of opioids. The surgeons don't care because they don't deal with the postop care beyond the wound. If the had to take care of these patients postop perhaps they would think twice about who they operate on.

 

[drusso]

Groups/stakeholders who *DO NOT* benefit from naming names:
feral providers
drug/pharma companies
hospitals
UDS labs
addiction mills
pill mills
injection mills
academics with pharma connections
impaired practitioners
professional societies

Groups/stakeholder who *DO* benefit from naming names:
patients

 

[kstarm]

What is generally the scenario in which you are called in? Overdose? Patient on COT has injury/surgery and "requires" large-animal veterinary doses of opioids that no one is comfortable with?
What is the hospitalist's/hospital's expectation of you in this case?
In my mind there is NOTHING worse than doing inpatient chronic pain consults in the hospital setting. Having done them as a fellow I know that they are an exercise in futility and a move to make you do someone else's dirty work. I had occasion to have lunch with the hospitalists at my local hospital last week. The first thing they wanted to know was would I be willing to see inpatient consults. Then they told me that they manage the perioperative care of all of the surgical patients including postoperative analgesia. They see tons of patients receiving COT who come in for surgery and require absurd doses of opioids. The surgeons don't care because they don't deal with the postop care beyond the wound. If the had to take care of these patients postop perhaps they would think twice about who they operate on.

The consults vary quite a bit. A lot of post-op pain management that spans from trauma with polysubstance abuse to little old lady sensitive to everything and doesn't want opioids. Acute opioid overdose issues, usually outpatient regimens from interventionally focused practices that are inappropriate regimens in an inappropriate patient. Acute radiculitis, cancer pain, burn pain, IT pump and SCS related issues, some suicide/psych consults in COT patients, Amputees, TBI, and lots of other stuff too. I don't see kids.

The surgeons manage the pain for post-op, and hospitalist manage pain for medicine patients. I provide recs. No call, no holidays or weekends. I have a program set up with neurosurgery where I consult on their high-risk patients before surgery and provide them with recs how to manage them post-op and then see them in the hospital to help carry out said plan. Neurosurgery does all the prescribing post op with my recs. If I recommend against surgery they won't do the surgery, saved a couple fusions with this program. Similar with total joint, though we have provided more education on how they can do it themselves without so much hands on from me. The way you talk about the hospital near you would make an inpatient pain job very undesirable (even more so than it already might seem to people)

Usually the information to the COT patient is "Because of your high tolerance there is little benefit in increasing your opioids further (assuming reasonable post-op regimen) and that is why we need to come up with additional alternative options for managing your post-op pain" All of which is true. Thus I am rarely ever going to "large-animal veterinary doses of opioids that no one is comfortable with"