Drug info - Pain management clinics..

[hamsterdam]

Are "pain management clinics" pretty much cash 4 candy places? Or will they actually scrutinize you more closely then an ordinary doctor?

swim's thinking about making his next monthly doctor's visit at a pain clinic instead of hitting up another random internist.

swim's health insurance doesn't need referrals.. $10 / office visit, specialist or not

[OhCasey]

Pain management clinics here in California tend to vary just like regular doctors. Ive been to some that are willing to prescribe strong opiates on the first visit and Ive been to others that want full medical records in hand and still wont prescribe any opiates on the first visit. It comes down to the personality of the doctor and how well you can sell your problem. Do a lot of talking about non drug related cures like excerise, acupuncture etc.

[hamsterdam]

problem is swim's age.. he's in his early 20s so selling a problem is tough.

After the high profile pill mill busts in the past few years.. doctors are scared of prescribing C-III (or C-II) substances..

[OhCasey]

I understand where swiy is coming from since swim is in his early twenties and has had doctors who put up a lot of resistance to prescribing opiates. The key for swim is he tried numerous non opiate related options like nerve blocks, spinal stimulater, accupuntcure, biofeedback and non opiate medications. The most important thing is to make the point that you cant function normally because of the pain and dont make a point of asking for a specific drug. Richard smoker wrote a great thread about this very thing and you might want to look at it http://www.drugs-forum.com/forum/showthread.php?t=17040

[pinksox]

They vary from place to place...usually even the ones that hand out narcs need to be pretty damn sure that SWIY has a legit medical condition that have the potential to cause pain. Now, of course, pain is subjective. Most don't hand out narcs to just anyone because their goal is to stay in business long enough to actually be able to help their real pain patients. Most also have pain contracts one needs to sign agreeing to only have scripts filled at ONE particular pharmacy and that SWIY will not get narcs from any other sources. A good many also conduct frequent, unscheduled urine tests. SWIMs has a policy of that any time she calls, that SWIM has to present herself within the next 24 hours to give a sample. Others do that AND have SWIY's bring in their pills for pill counts. The ones who stay in business the longest with the least problems with the DEA tend to be the ones that do all of the above.

So, no, pain clinics, for the most part, are NOT "cash for candy."

[hamsterdam]

Originally Posted by pinksox

They vary from place to place...usually even the ones that hand out narcs need to be pretty damn sure that SWIY has a legit medical condition that have the potential to cause pain. Now, of course, pain is subjective. Most don't hand out narcs to just anyone because their goal is to stay in business long enough to actually be able to help their real pain patients. Most also have pain contracts one needs to sign agreeing to only have scripts filled at ONE particular pharmacy and that SWIY will not get narcs from any other sources. A good many also conduct frequent, unscheduled urine tests. SWIMs has a policy of that any time she calls, that SWIM has to present herself within the next 24 hours to give a sample. Others do that AND have SWIY's bring in their pills for pill counts. The ones who stay in business the longest with the least problems with the DEA tend to be the ones that do all of the above.

So, no, pain clinics, for the most part, are NOT "cash for candy."

What's the point of the urine test? To make sure you're not taking other drugs, or to make sure you're taking your drugs?

It's hard for them to tell if you been taking too much or too little of your own meds.. given a day, if you been say, pushing your pills instead of taking them, you could easily just pop one and have it show up "correctly"

[pinksox]

To make sure you're not taking other drugs, or to make sure you're taking your drugs

Yes, both.

It's not hard if they send them to the lab for metabolites concentration amounts. People who use opiates tend to reach a somewhat "steady state" of metabolite concentrations. Between a persons individual metabolic concentration and known normal variant concentrations, a provider can pretty much paint a picture of what each of their patients ranges should be.

And, yes, theoretically, a person could take the day before and the day of and reach a reasonable concentration..but they'd have to do the exact same thing over time. And, smart providers augment urine testing WITH random call-in's for pill counts. If Joe has played with, or sold, his meds and his doc calls him and gives him 24-hour notice to come in for a pill count--Joe is going to either a.) be in deep shit for not having the proper number of pills..and likely discharged from the practice, or, b) be scrambling like a sumofobitch trying to find where he can acquire the proper amount of his exact pill type.

Of course, no provider can catch every diverter/abuser. Some are more proactive about it than others. And the proactive ones are the ones that tend to stay in business and retain their prescribing licenses the longest.

[hamsterdam]

ah, yes, but metabolite concentrations can vary widely based on how much water you drank before the test.

and anyone with half a brain (though a lot of drug diverters probably don't...) would keep enough pills on hand to pass a pill count.

[pinksox]

metabolite concentrations can vary widely based on how much water you drank before the test.

Yes, but docs are well aware of people drinking excess water to lower metabolites or try to show clear for other drugs. plus, it would be quite difficult to get it about right each time. Over time, patients show patterns and trends about what's normal for their personal metabolic pattern. One that fluctuates greatly over time is a big red flag for an observant doc. A sample marked as "dilute" will often make the doc re-test said patient...if not discharge them outright if they've had cause to suspect abuse or diversion in the past.

Personally, I think docs in general practice and pain management, should be much more vigilant in monitoring patients for abuse and diversion. One patient getting popped for diversion is going to bring increased scruntiny down upon that doctor. A bunch of patients doing the same, or overdosing, is likely to either a) have their license to prescribe narcs revoked, or, b) have their license to practice medicine revoked.

That not only puts the doctors livelihood and means of supporting their own families at risk, it puts all their legitimate pain patients well-being in jeopardy as well. Some clinics and pratictioners realize this and are very good at monitoring patients. Others have a lot of room for improvement.

PCPs, in particular, need to be much more careful. Longterm use of short-acting opiates is a prescription for addiction in SWIM's opinion...and there's lots of current and former addicts out there who can attest to that. People who didn't ask for these medications with the intent of abusing, using recreationally, as a lifestyle, or becoming addicted.

[hamsterdam]

True.. but if someone sticks to the routine of say.. "pop 1 pill the night before the test, and pop 1 pill the morning of..) they could get it about right every time. Unless of course they abused and took 10 the night before. (But people can always stick to say, abusing on friday night only, since presumably the tests would be on weekdays)

Or if it's someone who's not taking constantly, but on an "as needed" basis. For ex, swim wants 30 7.5mg hydrocodone / month on an "as needed" basis.

Maybe doctors should be warning people about how addictive this stuff is before giving it to someone who isn't asking for it. Someone who isn't asking for it is a hell of a lot more likely to develop a problem, since they don't know what they're getting into.

[pinksox]

#30 7.5 Vicodin PRN (as needed) is a pretty typical primary care physician-type script and might not have pain sufficient to warrant pain clinic treatment. Many docs(who care about maintaining their livlihoods) won't prescribe month after month after month of short-acting opies without referring the patient to a pain specialist. Then one of three things will happen. Either:

1. The pain doc will determine that the patient doesn't meet the criteria for longterm pain control with opiates and he'll refer them back to their PCP...who will have a VERY hard time continuing to prescribe monthly opiates at that point...maybe a few scripts a year, but not monthly.

2. The pain doc will determine the patient could benefit from other types of chronic pain management and will accept them for those types of treatment, but won't write for monthly opiates. Again, the PCP would be hard-press to justify writing continued monthly scripts.

3. Or the pain doc will determine that the patient has chronic pain of the type that can and should be managed both with opiates and conjunctive co-therapies and will accept them as a patient into their practice. At which time the PCP will no longer be able to prescribe opiates for that patient.

Pain clinics tend to manage those with chronic pain. People with "chronic pain" don't generally use PRN because they always or near-always have some amount of pain. Generally, pain clinics, will put their patients who need opiate pain control on a long-acting opiate like MS Contin, Avinza, Kadian, or Methadone. (Lots are actually moving more away from prescribing Oxycontin because of diversion issues and more PCP's are starting to prescribe oxycontin in their place). And then use a short-acting opiate for "breakthrough" pain on a PRN basis.

Some cat using their opies on a Fri/Sat night, who always made sure they had enough meds for a random pill count could potentially get away with it. However, they'd also have to ensure they could pass with "in-range" urine metabolites in their system when randomly called too. Some clinics even go as far as to limit the patient to presenting themselves the same day as called...which would make it difficult for said cat.

In SWIM's opinion, the best combine all of the above in sensible amount. A patient that presents within a few hours of being called, with a proper pill count, and who gives a clear, undilute sample with appropriate metabolite amounts is likely to be MUCH less of a concern to the doc for some time after that...unless the cat gives them reason to be suspect.

A person who avoids calls, fails to show, misses appointments, has tainted or dilute samples, or has samples with widely fluctuating or out of range metabolites or "pisses dirty" is likely to be looked at under a microscope at said clinic for a very, very long time...if not outright discharged.

Don't get SWIM's kitten wrong. It can be done...But it certainly takes some forethought and pre-planning to be done with little risk of ever being "caught." Of course, there are some docs out there that just don't seem to care...but most of them aren't pain specialists. Doctors who treat patients with chronic pain have seen all the angles, heard all the stories, and know all the schemes. The cat may think he's one-of-a-kind, but the doc probably has had 50 others just like him, LOL.

If all SWIM's cat is after is #30 7.5mg Vicodins a month, he may just want to try sticking with a friendly, but hurried and over-booked, PCP.

Reputation Comments on this post:

Post seems very intelligent and poster seems to know their shit when it comes to pain management clinics.

[hamsterdam]

well, the way swim looks at it, if he can get an easygoing doc, a 7.5/500 hydro/apap is CIII, and is writable for 5 refills/6 months, so he'd only need to get 2 scripts a year.. IF the doc is willing to give the script with said refills.

swim wants to build a medical history before trying to up his dosage (right now he's only actually using ~ 15 - 20 / month so it'll be a while before he decides to try getting more).

and swim by no means thinks he's one-of-a-kind and is almost positive that the doc's heard his story tons of times. he just doesn't act like a douchebag and intentionally throw up a billion drug seeker flags. (e.g. putting down allergies for every single non-narcotic pain reliever).

[pinksox]

and swim by no means thinks he's one-of-a-kind and is almost positive that the doc's heard his story tons of times. he just doesn't act like a douchebag and intentionally throw up a billion drug seeker flags. (e.g. putting down allergies for every single non-narcotic pain reliever).

Attitude is definitely important. And SWIM's "you" was meant in the rhetorical and not "you" literal sense. Then second most important thing is building a relationship with the provider. If they have a reason to remember you (and its a positive reason, LOL) that'll help build that relationship a little quicker. Give them a reason to remember you. There's usually a few minutes to engage in conversation not directly related to ones visit. Give them a reason to see you as an individual rather than just patient #45775.

Basically, it's just a matter of finding the right provider. Oldschool docs tend to be more lenient and understanding. Docs coming out of school the past ten years or so have had anti-opiate, abuse/addiction/diversion crap shoved into their heads til it came out their ears. Old schoolers tend to be a little more lenient because they're older and probably know what its like to hurt personally and because it hasn't been drilled into them as it has recent grads.

If one is smart, and patient, and knows how to act and what to say...and what not to say and he plays the game right and has a tiny bit of luck he could end up with a very reliable source of recreational entertainment. After that much of it depends on the doc and how diligent and vigilant about abuse, addiction, and diversion they may be.

[Ilsa]

Originally Posted by pinksox

Attitude is definitely important. And SWIM's "you" was meant in the rhetorical and not "you" literal sense. Then second most important thing is building a relationship with the provider. If they have a reason to remember you (and its a positive reason, LOL) that'll help build that relationship a little quicker. Give them a reason to remember you. There's usually a few minutes to engage in conversation not directly related to ones visit. Give them a reason to see you as an individual rather than just patient #45775.

Basically, it's just a matter of finding the right provider. Oldschool docs tend to be more lenient and understanding. Docs coming out of school the past ten years or so have had anti-opiate, abuse/addiction/diversion crap shoved into their heads til it came out their ears. Old schoolers tend to be a little more lenient because they're older and probably know what its like to hurt personally and because it hasn't been drilled into them as it has recent grads.

If one is smart, and patient, and knows how to act and what to say...and what not to say and he plays the game right and has a tiny bit of luck he could end up with a very reliable source of recreational entertainment. After that much of it depends on the doc and how diligent and vigilant about abuse, addiction, and diversion they may be.

spot on. kitten's been looking for literally YEARS to find a doc that will prescribe only clonazepam sans the usual antidepressant (the current dogma is that depression causes anxiety, and not the other way around), as her depression resolves when her feelings of being afraid and overwhelmed resolve. as with pain management, anxiety management meds are often subject to diversion, benzodiazepines in particular, and docs here in particular are afraid of having licenses pulled. she finally found, by word of mouth, a doc that will treat her severe anxiety with just a good old-fashoined benzo.

so looking for a certain type of doc can help....asking friends (not everyone, but good friends you know and trust) who have prescriptions how they had to go about getting them, how the docs were and the like can be very informative.

[hamsterdam]

Yeah.. swim's still in the process of finding a "nice" PCP doc to go to. Some doctors are just straight up against medication and are reluctant to prescribe anything (esp powerful narcotics).

[OhCasey]

Most pain clinics only test once and if the patient passes the drug test and doesnt display a lot of drug seeking behavior they usually dont bother with random urine screens. As far as testing metabolite concentration a normal pain specialist Dr would have to be atleast a little suspicious to go through all of that trouble. The problem with Dr's attempts to cut down on unnecessary narcotic prescriptions is often they dont help the problem of opiate diversion but instead they hurt the patient who really is dealing with pain. Even if youre trying to get a script for legitimate pain you have to sell your problem because of the way most doctors look at patients as drug abusers. In my opinion the under treatment of pain is a bigger problem in our current medical system than the abuse of prescription meds.

[Ilsa]

^^undertreatment has been a big problem for years....it's only getting worse with all the pressure being put on doctors right now...hell in my state there's an entire task force devoted to stopping diversion. they've allegedly even gone so far in some counties as to do pill counts a few days after a patient fills a script and if the count is too low the patient is charged criminally. not sure what the charge is and haven't found any news stories on it, but it wouldn't surprise me.

Reputation Comments on this post:

great point and perfect example

[OhCasey]

Originally Posted by Ilsa

^^undertreatment has been a big problem for years....it's only getting worse with all the pressure being put on doctors right now...hell in my state there's an entire task force devoted to stopping diversion. they've allegedly even gone so far in some counties as to do pill counts a few days after a patient fills a script and if the count is too low the patient is charged criminally. not sure what the charge is and haven't found any news stories on it, but it wouldn't surprise me.

I do think doctors should be vigilant of addiction but in my opinion its swung to the other end of the spectrum with pain management. The majority of opioid abuse by pain patients is because of the undertreatment of pain rather than the over prescribing of narcotics but that doesnt make for exciting news the way doctors being busted for handing out narcotics does.

[pinksox]

Depends I supposed.

I know one pain specialist who absolutely refuses to write for narcs for ANY patient on medicare/medicaid. His rational is that, because of financial issues, diversion to make money is increased substantially in that population. Personally, SWIM doesn't think that's horribly ethical...and may not even be legal...but kitten's yet to look into that aspect.

Perfect example in my Kitten's neighbor cat who gets 40mg oxycontins, prescribed by her PCP, after having a lung removed a few years back. She lives on about 20mg/day and sells the other "left-over" 600mg for $600/month.

My Kitten herself recently had a nightmare of an experience while switching from the pain doc she had for 5-year(who was 3-hours drive away) to someone local. My kitten saw that crazy bitch exactly 3 times before saying "screw this!" refused to go back, and had her PCP write her scripts until she could get into the pain specialist her PCP had recommended.

Now, the Kittens new pain doc just took over prescribing kittens pain meds from her PCP after getting to know her the past six-months. Kitten was taking 60mg Kadian(which she hated) twice daily and 10mg methadone tid with Tylenol #4 (1-2 tabs q 4-6 hours PRN #90/month). Kitten's new pain doc switched Kittens meds to 30mg methadone tid (90mg/day) with an extra #60, 10mg methadones prescribed/month for breakthrough. She also wrote for Zanaflax(tizanidine)2mg, 1-2 tabs q 6-8 hours PRN. And continued Lyrica at 150mg bid.

Lemme tell you cats...SWIM's kitten has been F.U.C.K.E.D.U.P.! She can't even come close to taking anywhere NEAR 90mg of methadone/day...never mind the extra 600mg for breakthrough per month. But, then, SWIMMY Kitty has also been pneumonia-sick the past week...but still. 40-50mg/day is holding her fine...and controlling her pain better than E.R. morphine. SwiKitty cut her right middle and index fingers with a crabby paring knife and didn't feel a thing a few days ago. Now, granted, Kitty has a little neuropathy in her hands...but gashes deep enough to require a plethora of bitty stitches and several steri-strips to boots shoulda hurt at least a little. SwiKitty just bled like a stuck pig..and bled, and bled, and bled, and bled...for HOURS...despite pressure, despite betadine ice baths, despite trying to close them with benzoin and strips...but she didn't feel a thing. In fact, Doc White sewed her up without Lidocaine even and swimmy didn't feel a bit.

SwiKitty doesn't believe in selling pills, but she doesn't have much object to finding some nice old female mama cat to trade for benzos with...cuz there's just no way on godsgreenearth SwimKitty can consume than quantity of opies per month...nor would she want to. Now, twelve years of so ago, LOL. Hmm, 'nother story.

SwiKitty, now just has to find a balance with the methadone that controls her pain but that doesn't mess her up at all mentally or physically. SwiKitty still needs to be able to work alertly and study without falling asleep or forgetting everything. Trouble is methadone has such a loooong half-life, it's hard to titrate it accurately in any sort of timely fashion. So far, however, it beats any long-acting morphine-type narcotic she's taken as primary hands down. Now, if she could just find that balance. ATM, she's falling asleep every time she tries to read.

[ConcertaXL]

Pain clinics are likely to prescribe strong narcotics if you can pay the price- going rate for fent or high dose of OC's is $1000+ a month (prices for specific clinics not allowed.) However if they do they will normally insist on a pain contract where you cannot get meds from any other source with regular UA's to prove you are following the rules. Some clinics in the UK are all about nondrug remedies, but you could ask before paying for an appointment. Of course saying "do you prescribe durogesic/ ms contin/oxycontin etc" is a red flag but you could just mention in a phone call/ e-mail that your pain is too severe for "alternative medicine" and you are sceptical about these treatments, so request "conventional analgesics" be provided.

[hamsterdam]

swim decided for what he wants (just hydrocodone), it's not worth going to the pain clinics.

The only things swim wants right now is either
a) hydrocodone
b) (something that won't be prescribed) morphine/hydromorphone ampule because he wants to try shooting it to see what it's all about.

[trannyboy]

SWIM has been having lots of major reconstructive surgeries, already nearly a dozen surgeries in less then 7 months. The surgeon prescribed 100# 2mg hydromorphone tabs PRN initially but SWIM has massive abdominal problems and throws up at least 6 times a day before any pain management/ surgery. The pain control wasn't working for SWIM because they just threw them up.

So SWIM went to their normal doctor and asked for #3 250mg hydromorphone powder vials per month. The doctor was fine with it because he knows SWIM won't sell or abuse it, is having major surgery and was prepared to be addicted until the surgeries were over. After a while SWIM had a tolerance and a minor infection. So SWIM went back to the doctor and asked for the 50mg/ml strength that comes in 1.25ml vials and the doctor prescribed 6 vials a day SubQ and 20 extra vials a month for IV use for breakthrough pain. SWIM now just draws up the dose each time and throws out the remainder in the vial. That way SWIM doesn't need to worry about tolerance or infection. SWIM rarely uses it IV because usually subQ is plenty fast enough most of the time.

SWIM never needed to sign any contracts, come in for counts or tests. SWIM's doctors knows and trusts SWIM and SWIM hasn't abused that trust. SWIM isn't sure how much it costs because the insurance pays for it and all SWIM has to do is pay 2 dollars a months but SWIM is sure that it is over 2000$ a month for his insurance company. SWIM says that this is much better then having pills that SWIM throws up and then can't take more because SWIM isn't sure how much he absorbed before throwing up and then having to be in pain until the next dose. Now SWIM is happy and healing well with only a few complication. SWIM always makes sure to treat the medication like they would in a hospital so that SWIM is as safe as possible. Plus with the extra that is in the vial SWIM can give a little extra every so often if SWIM wants to play a bit. SWIM only worry is that someone might rob SWIM. So SWIM bought a safe and bolted it to the floor, now SWIM has nothing to worry about until it is time to go to the hospital and be put in a coma and wake up clean.

SWIM says since SWIM gets what they need from their doctors they don't think it is important to involve a pain management specialist as well but if thats the only way you are going to get your meds, good luck it sounds like a real pain just to be out of pain.

trannyboy

trannyboy added 12 Minutes and 34 Seconds later...

Btw SWIM isn't trying to brag or anything. Just saying how SWIM gets their meds.

[hamsterdam]

Wait... you can shoot up 62.5mg of hydromorphone?!

That's one hell of a tolerance!

That doesn't sound right.. that a few 2 mg hydromorphone tablets will give you nausea but you're not dying off 62.5mg injected.. Are you sure it isn't 5mg / mL or something?

Anyway.. have you tried promethazine for the nausea? It works wonders...

[trannyboy]

I never said SWIM could shoot 62.5mg I said that is how much is in the vial. SWIM shoots between 10mg (basic dose to avoid withdrawl) and 25mg (dose to control severe pain) at a time from said vial and throws the remainder away. I said that having such a vial allowed SWIM to raise the dose in response to tolerance for quite a while before SWIM will need to ask for a larger prescription amount. I certainly hope that SWIM doesn't ever need a full vial as that is scary as hell.

SWIM hasn't tried promethazine nor has SWIM heard of it. Though it is important to remember that the vomitting isn't related to the narcotics and was present prior to the administration of narcotics so if promethazine is for opiate induced nausea then it might not work either. At this point the only two things that ever took away SWIMs nausea were metoclopamide and ondansetron.

trannyboy

[hamsterdam]

Ah, ok..

Does the vial not have that little rubber thing at the top that lets you stick the needle thru w/o contaminating the contents? That way you can use the whole vial (in multiple doses) safely. That's some pretty valuable stuff to throw in the trash.

Still though.. 10 - 25 mg of SQ/IV hydromorphone is HUGE. I mean.. that's like what? ~ 80mg - 200mg hydrocodone PO?