Pain Management

In most cases in an orthopaedic practice, the presenting complaint of the patient will be pain. The management of this pain can be very difficult. While the focus will be to try to find a treatable cause for the pain, in many cases, the pain cannot be completely relieved, and an important part of our pain treatment plan will include narcotic (opiate) pain medications.

The use of these opiate pain medications is really a double edged sword:
1) The good news: These medications can help with pain control.
2) The bad news: Based on the mechanism by which these medications interact with receptors in the brain, there is a significant potential to develop a tolerance to them (so the same doses don’t work as they do initially).

Also, although most patients take their pain medications as prescribed, there is a certain incidence of these medicines being used in ways NOT prescribed by the physician. This process, referred to as DIVERSION, can be characterized by medicines being stolen or somehow going missing. Narcotic pain medicines can be used for recreational use or sold on the street, an event which not only deprives the patient of the medications they need to alleviate suffering, but also endangers the license of the prescribing physician.

Here are some thoughts on how to regard your narcotic pain medications:

Tolerance: think of the example of licking an ice cream cone. The first lick allows all the flavors to be experienced, but with subsequent licks, your tongue gets numb. There is still a taste, but not like the first time. The longer time between ice cream cones (in this analogy), the more you taste it again next time you have ice cream. Translation, the more you save your pain meds for when you really need them, like when you are trying to sleep or get some rest, the more they’ll work when you need them to work.

Lost medications: Since the office policy is that narcotic pain medications are not refilled before their refill time is due, patients need to take care of their pain medicine just like they would take care of cash. Most people wouldn’t leave a hundred dollars cash just sitting in their medicine cabinet. They would keep their cash (and should keep their narcotic pain meds) in a safe, secure place, not where these items could be stolen. For the majority of prescriptions written, it says right on the prescription as a note to the patient that these meds will not be refilled early if the prescription is lost.

Doctor patient relationship: Occasionally, our office will get a call from a patient that their prescription was stolen, or they left their prescription in a hotel room, or the dog ate the pills, or some other excuse. Each of these situations would be judged individually, and there is no guarantee that an early refill would be given. If there is an early refill, the refill is made only on a one time basis, and guess what the answer will be if there is another incident and an early refill is requested? (hint: it’s not “yes.”). If this type of event occurs again, damage is done to the trust and credibility that should exist in a doctor-patient relationship.

The truth will be known (this scenario applies to a small minority of the patient population): These days with computer databases, pharmacies are tracking which patients receive which prescriptions. We have had situations where a patient will ask for and receive a pain prescription from our office, and then we receive a call from the pharmacy noting that the same patient has just received a similar prescription for narcotic pain medications from another physician. When a patient omits information about receiving pain meds from another doctor, we are happy to inform them of the good news that they can continue receiving medicines from that other doctor, as we will not be making any further refills. When this type of event occurs, the credibility of the patient has been damaged.

Pain Management Referral: Very often in cases with chronic pain, there are pain management strategies that are best handled by a pain management specialist. Our office can assist our patients in getting a referral to a pain specialist, but there is an important aspect to be considered: If a patient is enrolled in a pain management program, that relationship also has to be valued very highly. In other words, if the trust of the doctor-patient relationship with the pain specialist is violated, and if the patient gets fired from that pain management relationship, they may find themselves in a difficult situation indeed.

Once a patient has been fired from one pain specialist, it is almost like they are radioactive: nobody else wants to touch them. It is very difficult at that point (although not impossible) to establish a relationship with another pain specialist.

Most relationships with a pain management specialist, and some through our office, will require a Pain Management Contract, an example of which can be seen by clicking here.