Pain Management Community
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356518 tn?1322267242

Pain Management Rules.... Your thoughts and opinions

All of us know there are rules we must follow when in pain management and I wanted to start a post where everyone can add their thoughts or suggestions regarding the rules.
The first and most important rule is to always follow the Doctor's orders and do not deviate from them at all. When the Doctor prescribes medications for example you must follow the Doctor's orders to a tee or risk being dismissed or even red flagged.
In my opinion this rule is the golden rule. If we do not follow the Doctor's instructions then in my opinion we have no need to be in pain management because then we apparently think we know better than the Doctor so why waste their time and yours.
When the Doctor prescribes medications he/she is taking a risk because if the medications are abused or diverted it not only effects the patient but the Doctor as well.
When a patient is prescribed a certain amount of medications and they think it is not enough and then starts to treat themselves they no longer need the Doctor as they are simply self medicating. If the medications prescribed are not doing their job then it is time to speak to the Doctor and have the medications adjusted.

What are some of the rules that you have to follow and do you think it is necessary.
21 Responses
1401023 tn?1280784958
I had to sign a contract when I started with pain management for my lumbar herniation (now herniations).  It is the BEST tool for us and for them.  It protects us from ourselves.  Knowing that you can be tested at any time for any reason and if you fail you are kicked OUT is a huge dangling cookie to be good.  Is it tempting to take more when your meds aren't working well enough?  Of course it is.  I do other things, tho.  I use ice, TENS, stretching, meditation, etc to keep me from taking the easy way.  The medications we are on are serious and should be treated with respect.  I recently ended up to the ER when my disc bulge herniated, that resulted in being switched from 10/500 hydrocodones to 15mg oxycodones.  I'm not thrilled to go on a stronger med, but tolerance is going to happen when you have been taking a pain med for a very long time (18 mths in my case, and I never asked to be upped to anything stronger).  

One thing that does bother me is the instructions say Oxycodone take one tablet by mouth 4 times daily.  

In my opinion that leaves room for misinterpretation.  One could decide to take it every 4 hours during the day b/c that is when their pain is worse.  That is not what the doc means.  The doc means every 6 hours.  I stick to it like glue.  My meds are taken at 6am/12pm/6pm/12am.  As long as I keep the meds in my system at a steady rate my pain level stays steady.  If I miss a dose it is back full-on.    

Rules are there for a reason.  
Avatar universal
Hehe.  I hadn't seen this when I recommended you take your meds as needed depending on the time.  
Some doctors give instructions for "every 3 hours as needed" and some say "3 a day as needed", etc.  I do believe that's given to interpretation between you and your doctor.  I'm not saying I disagree with the way you do it, but it's just the rules my doctor has established with me.
Sandee, I am planning on commenting further, it's just 6 am and I need to wake up first.
1324871 tn?1288985306
I live here in Ky where there is a huge problem with abuse and  falsifying scripts. A lot of pcp will not write prescriptions for narcotics .I think the rules for pain management are necessary to protect PM docs and us .I signed a contract stating I would not get pain meds from anyone else .I also am subject to UA and pill counts .My PM has never done a UA or pill count on me but she can if she feels it is necessary .I have no problem doing whatever I have to continue getting my medication .It is a shame there is so much abuse of the system but I think legitimate pain patients should have no trouble complying with whatever rules the PM docs see fit to have .It is for their and our benefit .

Avatar universal
I agree that the doctors need to protect themselves and us.  And I am very fortunate in my pain clinic team in that we have open discussions and they give me the time I need.  I needed a lot of hand-holding with upping medications and/or changing to stronger ones.  My fear of addiction, though unfounded, is really high.  I know my surgeon got a little exasperated with me when I would say I was worried about addiction.  But the pain clinic NP knows it is a very real fear for me, especially since my ex-husband had addiction problems and I've seen it first-hand in my work as well.

But I disagree with discharging a patient immediately if the veer from their protocol.  I've done a lot of research on treating CP with opioids and addiction/tolerance/dependence.  Most studies show that addiction is rare in patients with CP.  It also states that usually if patients take more medicine it is because they are undermedicated to begin with.

And with inaccurate results from UA's, I think it's unfair to just drop a patient and let them fend for themselves or go into withdrawal.  I think it should be on a case-by-case basis.  And I think the way some of these pain doctors/clinics conduct themselves is a disgrace.  Doctors who will ONLY see the patient once a month.  Doctors who are basically bullies ... the "It's either my way or the highway" attitude.

Before I found this forum, I took my pain clinic and personnel for granted.  I can be seen at any time, usually the same day, if necessary.  We also use email and the phone as a method of communication.  When I had my surgery back in March, the pain clinic NP gave me her personal cell phone number to reach her on her day off and over the weekend if necessary.  Now, I would never take advantage of that, but I realize now how fortunate I am with my team.  Discussion about treatments, procedures and medications are a two-way street.  I never feel pushed into a procedure or medication that I'm not ready for.  And even though I do a lot of my own research, they never get annoyed if I need extra time to discuss the pros and cons of something.

It seems to me that so many people are fearful of their pain management doctors and I just think that's wrong.  I know there are a lot of people seeking drugs and that doctors have to be careful, but I think when there is evidence that you are in real pain and your treatment is necessary, the patient needs to be given the benefit of the doubt, within reason.  I see myself and my pain management team and my surgeon as a team that works together, and I expect the same respect that they give each other.

I know now how lucky I am that I found my pain management clinic the first time out.  Some of the things I've read on here strike me as abusive.
82861 tn?1333457511
mellie - GREAT post!  I particularly agree with your observation that fear is a very real part of many pain management patients' experiences.  I can't entirely blame that situation on the doctors.  Federal regulations force all doctors, not only pain docs, to practice defensive medicine.  They must constantly bear in mind the legal ramifications of everything they do and everything they say.  The result is that the doctor-patient relationship immediately begins on an untrusting and adversarial note.  If a patient and doctor cannot freely and easily communicate, the relationship is almost doomed to failure.

We see posts here everyday from people whose pain is undertreated wanting to know how to ask for something stronger or longer-lasting without appearing to be drug seekers.  The only reason these situations arise is due to federal regulations forcing doctors to assume all their patients are either outright addicts or potential addicts.  Communication is automatically stifled when patients cannot honestly inquire about a specific medication they may have heard about from online research or personal discussions.

The sad fact is that many people DO use the internet and forums just like this one to discover ways to feed an addiction through a legal source - doctors.  "What do I say how do I say it" questions may be perfectly innocent - or not.  There is no way of knowing.  

Then there is our own need for instant gratification to consider.  Life is so fast-paced today that we want instant pain relief.  Pop a pill, feel better in 20 minutes and go about your business.  Next thing you know you're self-medicating and adjusting dose times and it's off to the discharge races.  Pain management does not work that way, or at least, it shouldn't work that way.  Many doctors are guilty of not educating their patients about the reality of pain management and merely start up the pill machine.  The patient constantly complains that the medication isn't working, and next thing you know that same patient is discharged for addictive behavior whether he is a true addict or not.  Patient expectations of pain management are usually much higher than the reality, and the instant gratification monster roars louder with every passing day.  If we expect to have our pain "cured" by a pill, we're going to be in big trouble.  If a doctor takes the time to discuss the patient's goals and how various therapies can help reach those goals, the chances for a good outcome are so much higher.  So also is a thorough education of the risks and benefits of opiate therapy.  How many of us had such a conversation with our PMPs?  My bet is that number is pretty darn low.

I've been with my pain doc for 5 years now and I am very happy with her practice.  While she does use a contract system, I have never seen it enforced.  She does not perform pill counts or urine testing, nor does she require monthly visits.  Patients pick up Schedule II prescriptions when a refill is needed.  BUT - if a patient is constantly in her office and on the phone hysterically screaming about being in pain despite opiates being on board, she will discharge that patient.  I've seen it happen once in all the years I've been with her.  That particular patient was never going to be satisfied with any offered therapy.

The internet can be a wonderful reserach tool, but it hasn't done some people any favors.  How many times has a patient used knowledge gained on the internet to self-diagnose a medical problem?  He matches symptoms with something found online and goes to the doctor expecting the diagnosis to match what he learned.  If it doesn't happen the way the visit was scripted, disappointment and frustration drives the patient from doctor to doctor in a vain attempt to find one who will say what he wants to hear.  By all means, use the internet to education yourself, but take it with a grain of salt.  The final authority in diagnosis and treatment is the doctor.  Sometimes there ARE no instant answers and slow as it is, we need to let the system do its thing.

I also think it's a shame that the practice of medicine has become so fragmented.  I'm old enough to remember when the general practitioner (family doctor or primary care physician in today's parlance) was the most important person to a patient.  Nowadays, the PCP is used more for initial diagnosis and refers patients to specialists for actual treatment.  If a patient has multiple medical problems, he can end up with a doctor for nearly every body part.  Does anyone else find this situation cumbersome, time and resource consuming, expensive and unrealistic?  There is no reason a PCP can't lance a boil, but those patients are now commonly referred to a surgeon.  There is no reason a PCP can't treat high blood pressure, but those patients get referred to a cardiologist.  There is no reason a PCP can't set a simple bone fracture, but now those patients are referred to an orthopedic surgeon.  In this case, there is no good reason that a PCP can't treat pain, but now we are referred to pain specialists.  What a waste of education, talent and money!  

Before my mother passed away, she had SEVEN doctors.  The resulting schedule and medication conflicts were a nightmare and completely overwhelming to her - and me for that matter!  There's a reason for our ever-increasing health care costs and it's not the ever-trumpeted "greed" on the part of doctors.  The very system itself is a big part of that problem.

I see I've wandered completely off topic so I'll shut up.  LOL!
547368 tn?1440545385
Yes Mellie, great post.

Jaybay, I couldn't help but wander off topic with you. I too think that the specialist referrals have gone too far. You're correct. You could have a doctor for every body part. How many of us have multiple docs for this very reason. The PCP practice seems to have become so limited.

Gone are the days that your PCP treated about every thing. Medical science advancements, treatments and the like have become so vast that the PCP can not possibly keep up. I also think that when you add in all the litigation's a physician can not take the chance that they might miss an alternate treatment or medication....or miss a diagnosis I find it all a bit sad.

But I too miss the days that you had a GP who treated everything.....he was your family friend. And when he couldn't fix it all you needed was a general Surgeon. He was the local friendly town surgeon that did all types of surgeries. And yes, they were all males. At least the introduction of the females into medicine has been a wonderful progression.  

But when I was a child all you needed was two physicians. Guess that dates us.  :)  
1301089 tn?1290670171
I do what I'm told.  Shots, procedures and all.  I can have 4 lortabs a day.  If I only need 3 one day and 5 the next, she's ok with that but no early refills.  So I have to keep a good count on them and just have to be in pain sometimes.  Thank goodness she does realize my pain is different day to day.
Avatar universal
I was on oxycontin for 7 mos and just stopped taking it 10 days ago as I had a nerve block and was hoping that would deal with the pain, it hasn't yet and so I have booked a second nerve block with the hopes that it will work.  Right now I am pain killer free and not easily but I do not want to go through the withdrawl again.  Still not completly through it yet but pretty sure that I am over the worst of it.  I was given no restrictions for my pain management, no rules and was even given refills on my prescriptions.  I did not abuse my medication as I really didn't like the way it made me feel and the fact that it didn't take all of the pain away anyway, maybe reduced it from an 8 to a 4 but that was about it.  I was shocked thought that their weren't restrictions put on me, nothing to sign, no promise that I wouldn't go to another dr. or anything!!!!!   Not sure why this was.  I don't think my dr. knew what he was doing as when I decided to go off them he told me all it would be like is the flu for a day or two.  Boy was he wrong.  I was seriously ill for about 5 days and I still am having some withdrawl simptoms 10 days later.  A word of advice, talk to your dr. seriously about withdrawl before you stop taking them and have a plan, I didn't and I regretted it.  I don't think that I would recommend cold turkey like I did either.  You can ween off them and the withdrawl is alot less.  
Avatar universal
I agree completely about the PCP and Specialists.  It's particularly awful when you're exhausted and have trouble making it to one or two doctors.
I don't remember if I signed a "pain contract" with my doctor in the beginning or not.  I do fill out a form every visit that asks where/how my pain is and I sign it and certify that I have not recieved narcotics from anyone else in 30 days.  
Apparently the office policy there is that they write you a prescription and you are supposed to make it last the 28 days, no exceptions.  
But then, I've already explained how weird my PM office is.
270405 tn?1293039221
You know, I was just talking about this recently.  Its crazy all the specialists I get sent to.  My pcp just passes me off to the next person, and that person sends me to another person, etc etc.  There seems to be no single dr in charge of my over all care, and no real follow up either.  

I wish it were more like my children's pediatrician.  They just follow my kids health so much closer. If one of my kids needs to see a "specialist" then all those reports end up right back with the pediatrician, who most definately follows up.  Just recently, my 5 year old had her first UTI.  Of course I am so afraid that she may have inherited my kidney issues, so I made sure to tell her pediatrician my history as well.  Well, she tested my daughters urine before starting the antibiotics, and made us come in once she was done with the antibiotics to make sure it was gone.  I have never had a doctor follow up with me like that before!  Heck, I've even had doctors not even bother finding out the results at all.

Sorry, I am off topic a bit too.
356518 tn?1322267242
I wanted to thank everyone for their input. I agree with everyone and think we need to all stand up for our health care. It is our right to be treated and to be treated by medical standards and not the government or DEA standards. the DEA has made it impossible for the legitimate patient to get the treatment they need. All the while the abusers seem to have no problem at all feeding their habit off the very Doctor's that is to afraid to treat the people like you and me that really do medically need help.
The DEA's goal was to stop the abusers and diverters but all they have done is make it harder on us the legitimate patient. A person going to see a Doctor to get drugs for recreational use seem to have no problems at all. What is wrong with this picture?

I also wanted to comment on something Jaybay said.

She was saying alot of people will use support communities and forums on the Internet to obtain information on how to get the drugs they want to get high with. This is so true.
When I first came to med help years ago I would see different people daily here in our community trying to find out how to fake injuries and illness' to get narcotics. I was appalled to say the least.
This was before Med Help implemented the community leader program and I would basically tell them off and send them away and report them each time. They did not have a chance to try and find information here as I caught them every time.
I have seen so many great support forums/communities go down hill because these kind of people take over and turn it into a place to go to find narcotics and how to deceive the Doctor and get them.
We have worked hard trying to keep this community from turning into one of those places.
We still do get these people here from time to time and they always get caught and move along. We do stay on top of this diligently.
Med Help has been great for us and I do not mind giving back a little by being one of the community leaders that keeps these people out of our community:)
Avatar universal
I agree with the the discussion on specialists.  It gets draining.  When my mom was alive, so much time was spent going from one doc to another with nothing ever changing.  And it was exhausting for her.

I'm fortunate with my PCP.  She follows me for a lot.  Of course I see her for physicals and if I get sick.  But after my mom died and I was really depressed, I saw her a few times for that.  She was the one who diagnosed me with fibromyalgia ten years ago and while she did send me to someone else initially, because the flare-up was so bad, now she follows me for that.  She knows everything that goes on with my hands as she gets reports from the surgeon and pain clinic.  And if there was an emergency where I couldn't get help from either of them, my PCP would see me and evaluate my medication if necessary.  And since I'm not having any more babies, she does my pap smear and breast exam rather than me seeing an OB-GYN.

I think it is sad the family doctor doesn't really exist anymore.  I think we had better care when there was one person essentially overseeing everything.  Now I think it's harder to develop a real relationship with your doctor because you see so many different ones.

As for the internet, it's a blessing and a curse at the same time.  It's been a huge gift to me not only for learning things but also for passing the time.  But when I first searched for things having to do with my medication and pain management, I was truly stunned to see some of the sites out there.  I don't even know how they're allowed to stay up???  There are sites that tell you how to misuse your medication ... I read a few of them and it scared me to death.  These people have serious addictions and they're playing Russian roulette.  

I'm a big believer of having as little pain as possible.  But I'm also a big believer in that you need to be somewhat responsible for your own health.  I would never take something given to me by a doctor without first asking about it, the side effects, etc.  My BF drives me nuts.  He couldn't even tell you what he takes.  If the doctor prescribes it, he takes it no questions asked. I just couldn't do that.

This was a great topic!
Avatar universal
To MamaAng
  I agree with you 100% about sometimes what a doctor writes can be open to interpretation.  The best way to be sure you know what the doctor means in such cases is to ask him/her.  If you were in the hospital and and the doctor wrote for a med QID or 4xD without specificying times it would default to 9am, 1pm, 5pm and 9pm.  If the doctor wants q6h, he must write with the frequency q6h or specify give 4xd at 6/12/6/12.  To give a narcotic that is immediate release like percocet on a 4xd schedule @ 9-1-5-9 schedule makes sense as that is probably when the pain is greater simply because the patient is up and around, or at least awake. (I was a Pharm Tech for 34 years at a big ole hospital.)
As for rules.  When you go into pain management, save yourself a lot of turmoil and accept from the beginning that the doc's word is law.  There is little flexability or room for interpretation and the give and take of an adult relationship is nonexistant.  You are viewed with suspicion until proven otherwise.  For all this you may thank the DEA and all of the narcotic abusers and their prescribers.  Once I accepted those terms and quit butting heads, things improved greatly.  I've been on methadone for cancer related bone pain for a year now.  It has greatly improved the quality of my life and I have come to respect my doctor a great deal.  My advice is to just chill, do what you are told, and let the doc steer the ship.
Avatar universal
I agree with Sandee regarding all of the issues with the DEA.  Last night on our local news here in Florida they reported on a story of a couple who between them had over 1000 pills prescribed from ONE doctor and were heading back up to Ohio when the woman took some of the pills and the cops got called.  I was SO outraged.  
Here I am with ice on my neck, trying to minutely calculate how long I should use the heat and ice and whether it's truly bad enough to go to the ER and when I'm going to call my doctor next and if he's going to call me back and crying from the pain and stress and I see these jerks on TV who had tons of medication for problems they didn't even have!  Just to sell it because it can go for $80 per pill in Ohio.  It was just the icing on the top of the pain/anxiety cake.
I am seriously thinking about writing a letter to my Representative and Senators in Congress.  I am tired of seeing these drug dealers scamming doctors and real pain go untreated.  They need to have a better strategy in this war on drugs.  
82861 tn?1333457511
Another great post!  You said it all far more succinctly than I ever could.  Hope you stick around and post here more often - your pharm tech knowledge is a huge asset to all of us.  :-)
Avatar universal
Thanks for the kind words, they are a real energizer!  I  have posted 4 or 5 times and already I've mentioned being a Pharm Teach 3 times. I don't want it to seem like I'm hung up on the idea but it was just by way of explanation for the point I was making and how I came to make it.  I'm retired now but I believe my experiences will stick with me.  It has been an interesting experience to go from dealing with patients to being one yourself.  I've been really impressed with how many dedicated medical professionals I have met.  They have a tough job, especially with so many baby boomers starting to get sick!  I have a lot of respect for all folks working in the health care field.  Dealing with sick chickies can't be easy.
Avatar universal
Ironically, before I was injured I wanted to be a Pharmacist.  After taking care of my grandparents for a short time I got to know my way around the heart and diabetes meds.  I have learned a lot having to take a lot of meds over the years, but I know I couldn't be on my feet all day at any job, at least at this stage in my life.   I definetly have learned to appreciate a good Pharmacist, though.  I have had a couple of great ones and they make all the difference sometimes.  
356518 tn?1322267242
It is a shame that the ones who want these medications to use for recreational purposes can get them when the legitimate patients can not.
I can't believe some of the stories about this we get here in Florida on the nightly news. It is just outrageous!
We look to our Doctor's for the treatment we need to function and have some sliver of the normal life we used to have and they are too busy looking over their shoulder for the DEA to treat their patients.
Their are PMP's that do not let the DEA scare them and they do their jobs and take care of their patients because they do practice medicine to the letter of the law but they are few and far in between.
We need more Doctor's like them!
I wish I knew the actual number or even an estimate of how many legitimate patients do without pain management because of the ones who lie and cheat to get medications to get high off of. I will bet the numbers are astounding!
82861 tn?1333457511
Have you ever noticed that the clinics that seem to be the most tightly-run ships with pill counts and urine tests end up being the ones you see on the news?  We've had a rash of clinics being busted in Houston lately.  No doubt they had some legitimate patients who are now in a terrible bind because the clinics are shut down, but it turns out most clients were addicts.  The doctors saw a quick way to get rich and grabbed the ring.  Now their licenses are gone along with all that money.  It just makes me sick.

The media hasn't helped the cause of legitimate patients either.  Think about Michael Jackson and his doctor abusing propofol for a sleep aid.  My pain doc is also my gastro doc's anesthesiologist and they both prefer propofol for EGD and colonoscopy anesthesia.  It's fast acting and actually safer than the older fentanyl and versed mix.  She told me that a raft of patients refused propofol because they were convinced it would kill them.  No amount of education would change their minds.  

The reason legitimate patients can't even find oxycontin is also thanks to overblown media stories about overdose deaths.  They did a terrific job of demonizing a perfectly safe pain medication by publishing sensational stories about people who abused it.  How many people now refuse oxycontin when it is prescribed simply due to the bad press?  They "heard" it was "deadly" and refuse pain relief.  It boggles the mind when you think about it.

PMPs aren't the only doctors who must practice defensive and adversarial medicine.  All docs must be constantly alert to the possibility of a lawsuit in everything they do.  HIPPA laws alone stifle communication as I discovered so easily when dealing with my dying mother.  Federal regulations force all doctors to assume their patients are addicts and treat them accordingly with no evidence whatsoever to back up that assumption; hence the adversarial relationship from the beginning.

All of this is just one reason I am tapering off the fentanyl I've been on for 5+ years.  I see the writing on the wall.  We have to jump through enough hoops as it is, and with Obamacare looming it's only going to get worse with government even more involved in the patient-doctor relationship.

I'm sick of being dependent on opiates and the constant worry about protecting them, planning ahead if I go out of town, wondering if this year will bring another hurricane and close the doctor's office and pharmacy.  Two natural disasters and associated delayed refills showed me just how dependent I am on pain meds and it's not a good feeling to a woman who likes to be in control of her own destiny.  

Frankly, I don't even know that they're helping all that much now.  Maybe I'll find out otherwise as the dose goes down and change my mind, but I have to give it the old college try.  If nothing else I'll be able to get along on a lower dose.  In the past month I've tapered the fentanyl by half without too much difficulty, but have no doubt the hard part is just beginning.  My goal is to ditch the fentanyl and have norco on hand for only the worst obstruction episodes.  At least that way I have some tiny bit of control and won't be quite so much at the mercy of the powers-that-be.
Avatar universal
" All of this is just one reason I am tapering off the fentanyl I've been on for 5+ years.  I see the writing on the wall.  We have to jump through enough hoops as it is, and with Obamacare looming it's only going to get worse with government even more involved in the patient-doctor relationship."
  "The reason legitimate patients can't even find oxycontin is also thanks to overblown media stories about overdose deaths.  They did a terrific job of demonizing a perfectly safe pain medication by publishing sensational stories about people who abused it.  How many people now refuse oxycontin when it is prescribed simply due to the bad press? "  Jaybay

  Overblown media stories may be at work in Obamacare as well as stories about Oxycontin.  Remember that we haven't seen Obamacare in play yet and always ask yourself when someone is criticizing efforts to improve improve health care who their "dog" is in the fight. (I'm NOT talking about you, Jaybay, I'm talking about people in media stories)  There are two things I know to be true at this point:  The vast majoprity of medicare patients (gov. run) are quite satisfied with their care, and when Obamacare begins, it won't change a thing for me..I receive coverage from BCBS and will continue to do so..
Avatar universal

  I feel for you and worrying about getting/keeping your drugs in supply.  What my doctor does is give me a 30 day supply and schedule my appointments every 28 days.  That allows me to build up 2 days worth every month.  Right now I have 20 tabs built up in my "super secret stash"  that I'll have if an emergency strikes or I have to reschedule an appointment.  Basically I'm able to put away 5 tabs a month the way she does things.  Maybe something similiar would work for you?  I know the fentanyl patches are q3D or q72h but the glitch is how much your insurance company is micromanaging when you get your refills.  When the pharmacy is saying they can't refill something, most times it is because the insurance company says no (meaning no, we won't pay for it, it's too early).  I hope you can find a way to make things easier.  I'm sending good thoughts your way. :-)
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