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Thursday, January 20, 2011

The Search for Pain Relief

Today has been a long, and frustrating day. First the new rheumy cancelled my appointment because of the weather. I know my GP doesn’t want to treat my pain, and I have held on and pushed through knowing I would be seeing the rheumy. So, back to the GP for help till I can see the rheumy. His first response was to schedule me with a different rheumy in April. I counter with a request for pain clinic, waiting to see if my insurance will cover it. His next offer was Tramadol which makes me ill interacting with my Prozac. These calls started at 8:30am and the Tramadol offer came at 4:30pm. I sit back in the recliner and start searching for other pain clinics around and thinking about my life. I have RA, no one doubts I have RA. For Doc’s that like numbers, mine leave no doubt I am in pain. For those that watch the way I walk and move, there is no doubt I am in pain. Yet, Doctor after Doctor treat me as if Advil should make me well, and if not I must be a drug seeker. I tell them over and over, I will sign anything, I will take drug tests, I will pick them up 2 at a time, I will jump through any hoop you design just make the pain tolerable. At 5:30 the GP office calls again and he is going to call me in 30 Vicodin that will need to last me till April. I was so relieved to know that I have something to dampen down the pain when it is at its worst. This isn’t going to improve the quality of my life, it is no where near adequate pain relief. It will however keep me from the brink where the pain is so bad that death is actually a preferable option.

This is where I have been today. Searching for pain doctors did not help my frame of mind either. I found a pain doctor that is a reasonable distance from me and started searching for his research, papers, etc. What I found really upset me. This is the evaluation tool for determining if a chronic pain patient is high risk for abusing pain pills. A score of 3 is high risk. I am working on breaking the list down and discussing each part, but for now, how does your search for pain relief reflect on this tool?

1. Focus on opioids

• Not interested in non opioid modalities

• Not interested in workup of pain or referral for workup

Physician feels that patient is focused on opioids

• Demanding opioids

• Angry if denied opioids

• Asking for higher doses of opioids

• Asking for opioids on the first visit

• Asking for and/or insisting for specific opioids

• Claim allergies to all/most non opioid analgesics

2. Opioid overuse

• Self dose escalations and asking for more

• ER visits for opioids

• Asking for opioids on weekends and after hours

• Stolen/lost prescriptions and asking for more

• Taking opioids from nonphysician sources

• Excuses to obtain additional opioids

• Hospitalization for unexplained exacerbation of the chronic pain

3. Other drug use

• Prior alcohol abuse or illicit drug abuse

• current use or asking for benzodiazepine/soma

• current use or asking for barbiturates

• current use or asking for stimulants

4. Low-functional status

• getting financial assistance(non-retirement) from the State

• getting disability benefits

• Applying for or planning to apply for disability benefits

• On BWC, but not working and getting financial assistance from BWC

5. Etiology of pain unclear

• History, physical exam and investigations unclear in explaining pain symptoms

• Nonphysiological pain patterns like diffuse pain, whole body hurting, pain radiating up or down the spine

• Inconsistent pain patterns

• Investigations normal

• Investigations don’t explain or correlate with the symptoms

Physician feels that the etiology of pain is unclear

6. Exaggeration of pain ( again really??????)

• Exaggeration of pain symptoms

• Positive Waddell signs

• Unexplained moaning and groaning with slight movement

• Unexplained difficulty with movement

• Exaggerated facial expressions during physical exam

• Unexplained extreme limitation in the range of motion of the spine or joint

• Cannot clearly justify use of cane or walker or wheelchair

• Unexplained worsening of Pain after physical exam

• Cannot complete physical exam because of pain which cannot be justified

• More than expected tenderness in the area/areas of pain

• Pain out of proportion to the findings on investigations

Physician feels that patient is exaggerating pain

http://www.painphysicianjournal.com/2004/july/2004;7;333-338.pdf

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