Sean Mackey on Pain Medicine's Civil War

[drrosenrosen]

this is excellent medical treatment. kudos to you. i am glad someone is willing to do this work

i personally find that sort of work tedious, non gratifying, not appreciated, argumentative, potentially dangerous to myself and staff, and not remunerated well

Honestly if it's an opioid patient who is giving me problems, they're not likely to stay on them for long anyway. People who come up short, ask for early refills, have inappropriate UDS, are asking for dose increases, end up getting tapered or discontinued (fire the drug, not the patient, right Steve?)

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[SSdoc33]

Honestly if it's an opioid patient who is giving me problems, they're not likely to stay on them for long anyway. People who come up short, ask for early refills, have inappropriate UDS, are asking for dose increases, end up getting tapered or discontinued (fire the drug, not the patient, right Steve?)

yeah, but that in and of itself is a PITA. i have enough trouble parenting my kids -- dont want to have to parent my patients as well

 

[drrosenrosen]

yeah, but that in and of itself is a PITA. i have enough trouble parenting my kids -- dont want to have to parent my patients as well

Fair enough. Like I said, I was dealing with very high dose opioids at my last gig, so this is nothing for me. Pain threshold (my mental pain) is a moving target. I am below my pain threshold currently with what I'm doing.

 

[Baron Samedi]

What percentage of y'alls opioid pts are ones you started them on? Mine is <5%, the rest are other peoples' messes that I've inherited.

So glad the DEA is requiring that 8hr training, so when PCPs try and dump their pts on us because they're "not comfortable prescribing their opioids anymore" I can reference the fact that they had mandatory training on the topic.

 

[drrosenrosen]

Yeah most of the non-tramadol, non-bupe pts I have are inherited. I try not to inherit projects, but if I see a pt who's on more than I want to manage, I just tell them straight off on the first appointment that my plan will be to taper them down, no questions. If they want to go ahead with that plan, we do it. If not, they find another doctor.

 

[Baron Samedi]

Yeah most of the non-tramadol, non-bupe pts I have are inherited. I try not to inherit projects, but if I see a pt who's on more than I want to manage, I just tell them straight off on the first appointment that my plan will be to taper them down, no questions. If they want to go ahead with that plan, we do it. If not, they find another doctor.

Will be nice to longer be in academics and have a say!

 

[Agast]

Will be nice to longer be in academics and have a say!

Why aren’t you allowed to turn down opioid patients in academia? One of my attendings did it all the time

 

[drusso]

Soooooo many generalizations in this thread.

Generalizations are all we have. No data, no mission.

 

[Baron Samedi]

Why aren’t you allowed to turn down opioid patients in academia? One of my attendings did it all the time

The DoD in all its wisdom came out with guidelines that state anyone over 60 MEDD needs to be seen by a pain doc, and as an academic center we get all of them.

 

[Agast]

Oh, he saw them in clinic, billed for the office visit and said No at the same time

 

[BobBarker]

The DoD in all its wisdom came out with guidelines that state anyone over 60 MEDD needs to be seen by a pain doc, and as an academic center we get all of them.

DoD? So active duty soldiers?

 

[GoBeers]

The DoD in all its wisdom came out with guidelines that state anyone over 60 MEDD needs to be seen by a pain doc, and as an academic center we get all of them.

my interpretation of "need to see pain doc if MED >60" is so the patient can be offered therapies other than escalating opioids because clearly opioids aren't working.

but i understand if all other physicians interpret that phrase as "if you need more MED , go to pain mgmt"

 

[deleted131481]

Patients I start on tramadol or buprenorphine are generally very easy to deal with. I won't suggest starting opioids on someone unless I really think it will help and I know the patient after a couple visits - you get a good sense of who will cause trouble and who won't.

It's true I'm not measuring their steps, but I have more than a few elderly patients who have decided to forgo what could be a rather extensive surgery because the tramadol/bupre is enough.

The opioid patients who have given me problems are inherited. These are tapered off, converted to buprenorphine, or blame the government and leave. I'll say though some of these are stable and have been on <30 MME for a decade+.

 

[Baron Samedi]

DoD? So active duty soldiers?

Primarily their dependents or retirees. I don't have too many active duty folks on opioids.

 

[kstarm]

Dr. Sean Mackey: Tools to Reduce & Manage Pain

In this episode, my guest is Dr. Sean Mackey, M.D., Ph.D., Chief of the Division of Pain Medicine and Professor of Anesthesiology, Perioperative and Pain Medicine and Neurology at Stanford University School of Medicine.

www.hubermanlab.com

I like the Huberman podcast and this one was interesting. About 3 hours!, I listened to a few sections including the opioid section (Starts about 1hr 53min in). Some things missed in my opinion but seemed like a relatively balanced take on opioids. Really no interventional came up in what I was looking at. Seems weird that a whole section of management is left out (or at least not with what I listened to).

 

[MitchLevi]

He's a fantastic educator and generally great pain doctor. He lives and exists in a fantasy world at times, and he's clearly on the spectrum.

He annoyed TF outta me during fellowship, but in hindsight he's a gangster. The guy is legit.

 

[SeniorWrangler]

I've talked to a lot of PCPs in the past when I did a lot of pain education, and most of them just got tired of trying to keep up with the twists and turns of opioid policy and all the controversy and all the mandated tests and assessments and checks that prescribers are told to do. If you just say "No", all of it goes away. I can understand why so many providers are opting out of opioid prescribing if they have the option.