Do you do your own pain management protocols for patients requiring medication for a chronic problem or do you refer them to a pain management specialist?
I manage patients' chronic pain myself.
(2 votes)
I refer these patients to a pain management specialist.
(2 votes)
  • Comments (24)
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  • Pain and pain mgmt is an all too misunderstood entity.  Not enough physicians have experienced it themselves so they do not have a true perspective of it.  I'm not saying that they should.  I would not wish a horrible medical, surgical, or traumatic episode or long-term condition on anyone.  However, it sometimes requires real perspective in order to get a proper grasp on something. 

    I know of a pain doc out here where I am who, via an incident and then treatment ended up becoming pain certified; knowing it motivated him to become an expert on the thing.  I know other docs who saw too many patients with certain un-treated conditions who then went and studied these things in-depth, became certified, and now are the experts in their field, renowned even.

    Not sure what the upshod for most of us would or should be from the last 2 paragraphs, but I do know this:

    It starts in the schools.  Then, it must follow into the residency training.  And the students must demand it.  Just like the first schools there ever were... which were demanded by greek students themselves.  That's right!  Education was originally NOT foisted upon young people who were forced into becoming students; it was the other way around.  Young people wanted to learn, so older, wiser, learned men were asked to instruct them in oratory, logic, argumentation, the maths, etc.

    So, as these pathological entities exist, pain, chronic pain, and whole host of other non-surgical conditions which can be treated via clinical means, therefore the skills must be brought to the foreground and taught on an in-depth basis.  And for my part, once again, to underscore what I have said above already: that did not happen to any significant degree when I was in school nor while in residency.  For example, the teaching of injectables and injection techniques was given rather a cursory look and quick once over workshop.  To that, I must say, in our world, in our practice, for our patients, that simply does not suffice.

    Now, I consider having gone out and made myself much more advanced in these areas via the ways and means I have already described.  But I have seen far too many who are flying blind.  There is far too much "mythology" going around and a palin & simple "lack of skills" out there within our own profession in the areas of injectables [knowldege] and injection techniques [skills].

    As for pain mgmt, too many Pods shy away from it because of a lack of knowledge, comfort level, skills, and/or it just plain scares them.  Pain and pain mgmt are blind spots.  This leaves too many patients in too many places w/ lower extremity, foot, and ankle pain with no where to turn.  The articles and books on this subject are clear:  pain changes the brain chemistry.  Without relief, people can not sleep, can not be productive, and enter a world of DSM-IV codes that they would not otherwise if their pain were well-controlled.  We can offer them clinical treatments, and referrals to pain mgmt and even recommend an implant such as an IPG (like a TENS) be put in (by a procedural interventionist, i.e., CRNA who does pain mgmt).


    Again, we need to change up the topics at the conferences, invite different speakers, and move forward with the times and the pathology that's actually out there.  I think we've got too many conferences with the same people blathering on about the same stuff: HAV complications, a new Lapidus, this HT implant, etc., etc.  In the 2000's, I think I had been to 3-4 different conferences and workshops in the SE, SW, & midwest where I'd seen the same slides by the same speakers over and over!  I had new slides, new cases, & new topics never before seen in books from the GWOT, but no one would let me get up and speak.  Maybe I was no one's favored son or not in the right club; I dunno.


    Like Forrest Gump sez:  that's all I have to say about that.




  • Perhaps, we don't see enough of it at conferences because the profession is still hung up on surgery, surgery, surgery.
    I must applaud Dr. Bijack for his last remarks on PM News (I do so because many of his comments in the past were abrasive and I believe due to the crux of his many remarks, he has often taken on criticism.)
    But, he pointed out that we seem to have forgotten what a podiatrist is. He remarked that we would do ourselves a big favor by being better educated/trained in medicine like medical students/residents are. I think there is merit in his words.
    Pain management, fall prevention, skin disease, PAD etc etc should be the foundation of our specialty. Surgery should be learned, and is definately part of the paradigm, but the foundation must be solidly laid.
  • Re: Pain Management Can Be a Pain – do you do it yourself?
    Dr. Godfrey's answer is one of the BEST responses I have ever read. I learned so much from your post. I, too, want more conferences about things that matter - like continued education about the medications that we use to treat our patients.
    ACFAOM's contribution each year to the APMA National Scientific meeting has been very well received in that regard because it centered on good practices for those clinical situations we actually see.
    Unfortunately, the APMA has dropped their affiliates day at the national, at least for this year. They are afraid that the new physician's sunshine law will cut back on their sponsorship dollars and it is very expensive to get the APMA, in mass, to Hawaii for a week and back. The casualties were the affiliates this year. Too bad. Unfortunately I usually don't need to know about the latest implant for the third toe of the left foot in right-handed plumbers - LOL!
    But back to pain.....there is a lot of it out there. It reminds me of another topic and instead of morphing into that, and incurring the wrath of others, I will start a different thread.
    Thank you William Godfrey for the great information. I am interested in the longer acting local and want to find out more about it. I agree that the topicals are an interesting way to go and I have prescribed those over the years. I've had pretty good luck with the topical Voltaren but patients have to be willing to use it faithfully for a longer period of time. It's not as simple as one application and pain is gone.
    I work in an academic environment and we talk about evidence-based medicine every single day, if not every single hour, and I am amazed that my colleagues will often revert to anecdotal, judgemental experiences with patients with CRPS. "They are hysterical women with psychological problems!" Au contraire, mon frere. We are compiling a meta analysis of current treatments and diagnostic testing for CRPS as we speak and it is proving interesting.
    A newer faculty member here asked me one day why the profession was ignoring the science about CRPS and I thought that it was probably the fact that we remember what we see and most of us have had a CRPS patient, unfortunately. By the time that they get to us they are often at "the end of their rope." Depressed, passed around from one physician to another without answers, and treated like a malpractice case in the making. It's natural to remember that one person rather than the science of it.
    Stay tuned. I think our article will provide some interesting outcomes and I hope will help us to think, as a profession, beyond the incorrect information that we were sometimes told 20 or 30 years ago (or even five or 10!)
    This is my opinion only and not that of my employers or associations with which I am associated.
  • I do a lot of clinical services, e.g., injections (local or proximal blocks) for this.  I used to have access to extra lon lasting local anesthetic (72 hours) in the military.  It had to be kept in the cooler and then in the dark once removed from the cooler.  I would get it from the CRNA's.  As of last year, I would still get a lot of wounded warriors and veterans for whom I treat their chronic pain, and often move to the multi-disciplinary team approach; these patients seem to appear in waves based upon re-deployment back from overseas.  I had a good relationship with the unit & VA on post.  No other Pod in town seemed to know what to do.  I worked a lot with them while in the service, and studied alot about this condition, as well as hosting CME talks from Pain Mgmt depts from the University Medical School (PhD's & MD's), so I learned a lot about it.  Plus, I cross-consulted with the civilian Pod where I was stationed, and we traded clinical treatment techniques (injections, mixtures, etc.).

    I also prescribe (and demostrate how to utilize) a lot of Lidoderm, Lidocaine ointment or Lido-gel, and other topical preparations such as those w/ an NSAID base, i.e., Ketoprofen.  Some pharmacies carry a prepared item; other pharmacies compound various preparations; while still other Rx reps promote a mail order item. 

    Some patients prefer an all natural approach; so, I will have them pick up Traumeel oint or gel from the local health food store; this works only if they use it on clean dry skin, 3-5x/day, and takes effect after 3-5 days if the problem is severe for pain, swelling, bruising, & inflammation (as well as not too deep); I have a subset of pts who claim excellent results.

    I feel that this is a huge area of pathology that needs to be studied, researched, written about, and taught in the schools and residency programs.  With the large and growing patient populations of wounded warriors, injured people, and aging population, I am certain that this demographic is going under-diagnosed, under-treated, and we are not serving them properly nor fully as specialists of the lower extremity.  In fact, I would go so far as to say that for most Podiatrists, chronic pain in the clinic, treatment of a non-pharmaceutical nature is a blind-spot.  This needs to be rectified.

    I for one am sick and tired of seeing the same old tired topics at the conferences. 

    Where is chronic pain mgmt being addressed?  No where, no when, and no how. 

    We are not up to date with the pathology of the current and changing demographics.


  • First of all, the name is Kathy to all here or Kathleen if you want me to think you are angry with me.

    I would really enjoy hearing from this fellow who is a strong user of Sarspin. I am always open to new things...even new, OLD things.

    Have you noticed how many meds and treatments tend to hark back to earlier things? The more research that is done on disease in general shows that the principle factor is inflammation.

    Cancer? Inflammation. Arthritis? Inflammation. Heart disease? inflammation. So, if we were all on low dose ASA would we be staving off major diseases?

    Forget fluoride in the water supply! Think about non steroidal anti-inflammatories.

  • Dr. Satterfield - I don't know if you know him, but Dr. Diamond,out of Philadelphia, who informs me he does a lot of chronic pain management within his practice is a big user of Sarapin. I will try and email him and see if he could comment within the blog.
  • David Gottleib said:

    BTW, properly tritrated there is NO upper limit to opiod dosage, but it has to be properly tritrated.

    Dave Gottlieb, DPM personal opinions and experiences only


    Amen! Hallelujah! I learned this in a very emotional way.....

    It was my first month in my residency, at West Haven VAMC in Connecticut. I was "lucky" enough to draw the General Surgery rotation first and those were the days of 36-hours on, 12-hours off. Eighty hour work week? "We don't need no stinkin' 80 hour work week!"

    One night, as the day team was passing off to the on-call team, the chief, a European 5th year chief resident from Yale was giving me my overnight instructions for a patient dying of disseminated bone cancer. It was an incredibly painful process and he was suffering. She told me that I should increase his morphine as needed and to not worry about the amount. No matter how much I gave him, it would not be enough to "kill the patient or kill the pain."

    Wow. When she told me the beginning dose, which I don't remember now, I was flabbergasted. It was something like three or four times a lethal dose!! Imagine me, the podiatric resident, first month, first rotation, being told to push morphine at rates that would kill an NFL football lineman. I was hesitant to say the least.

    This wonderful doctor took my hand and said "What are you worried about?" and I said "I'm worried about killing him. He's going to stop breathing." She looked me straight in the eyes and said "And would that be a bad thing."


    I remember telling her that no, it wouldn't be, because of his pain, but that as the podiatry resident, first year, first rotation, I didn't think that it should be me doing it....hell, even if I was the chief resident, I wouldn't feel good about it. That's how I roll. But she smiled a wonderful calming smile and explained that he had been acclimated to these high levels over several months and that not even me giving him these requested doses would kill him.

    She seemed so sad about that, as if she wished that God would take him right then and there. This man was absolutely writhing in pain. That night, as his pain escalated, I gave the order to the nurses and they didn't blink an eye. They drew it up and gave it to him. He was calm for a short period and then, again, the pain returned as I was going off service.

    I will never forget the Yale chief surgery resident, that patient or that night. It proved to me that the human body can be both a wonder and a hell.


    These opinions are those of my own...not my associations or employer


  • Quote:

    Good point, David. Thanks for speaking up and expressing your practice habits. So, what are the criteria that you use to make the choice between the ones you keep and manage and the ones that you refer to a specialist?


    Some patients have obvious joint damage and don't want or can't have surgery. They are properly braced and biomechanically supported as appropriate. They will get gradually worse but never better. I have no problem with Rxing low dose chronic opiod in these cases. One of my colleagues is comfortable Rx'ing continous acting po morphine. I don't have a problem either in the right patitent.

    Every patient asking for opiods is not an addict. And every addict asking for opiods aren't just asking for opiods. An addict can have pain of a level that opiods are also required. It's a matter of evaluating the patient and being sure what the opiods are for.

    At my institution we have a Chroinc Pain Management service that does a wonderful job. They expect a full evaluation before the referral and all patitents sign a pain management contract that is strictly adhered to.

    The Acute Pain Management team is the service treating the condition. We handle all post op pain using all medications at our disposal. TENS doesn't seem to be of much benefit.

    So, before I wander off course, I hope that answers your question.

    The American Academy of Pain Management is a wonderful resource for information on pain management, as is the site [I dont' think they are connected]. Lots of good information on dealing with chronic and acute pain.

    BTW, properly tritrated there is NO upper limit to opiod dosage, but it has to be properly tritrated.

    Dave Gottlieb, DPM personal opinions and experiences only

  • I've pretty much stopped writing for opiods.  I'll treat the pain with non-narcotic analgesia in addition to appropriate non-medicated pain treatments based on each situation.  Once they start needing more advanced pain management they get referred.  It's just too hard for me to determine whose a drug seeker and whose not in some cases.  Plus, if they really aren't getting better with the less potent treatments, I want to get them to someone who can offer treatments that are out of scope for us. 

  • Kathy:

    My understanding is that these docs were asked to provide chart notes and when the insurance/gov't read that Serapin was injected they asked for the refund going back three years.


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