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Primary Care Physician for Pain Management?

NVANNVA Posts: 17
edited 06/11/2012 - 9:01 AM in Pain Management
Hi, all. I have an appointment with a new primary care physician tomorrow (haven't had one before now). The doctor I've been seeing for pain management (referrals to PT, medications, etc.) is moving his practice out of the area.

Any advice on how I might engage my new PCP as the single medical provider? As I mentioned in a previous post, I have five kids under 10, work many hours a day, and it's difficult to coordinate and justify multiple appointments each month. Ideally, I'd cut out schedule II controlled substances and just take Daypro once per day and percocet as needed, instead of Oxycontin twice a day. I'd like to ask the PCP for a referral to a chiropractor as well...time to try again. I'm miserable with SI joint, facet joint, and sciatic nerve pain.

Others have suggested a physiatrist. I've left a message with one office and haven't heard back yet.

Thanks for any input you have.


  • This is where I began my PM at too. In fact, my PCP still writes all of my prescriptions and everything related. I've been seeing him for 3 years now.

    What I like about him is primarily this -

    1. Most important, he believes me and trusts me. This is paramount I've found, especially if you take narcotics. As much as I hate to say this, if you take narcotics, be prepared to be scrutinized by darn near every other doctor you visit. This has been my experience and I work full-time, have no addiction history of any illegal or legal drug. I take a schedule III drug. If you're pain requires more, a PM clinic might be necessary. I dunno, I've never asked for anything stronger, but I would presume he might have a problem writing a prescription for schedule II drugs. Again I've never asked nor will I. I let the doctors choose my medicine(s), then I let them know how it does.

    2. He's been seeing me for 20+ years. This goes back to him knowing my medical history, etc, etc. In your case the new doctor will not know you. You'll have to build a new relationship and trust me I know it's difficult.

    3. The Health Company/ Hospital group he's associated with has all of my records, surgeries, etc. Basically saying if I do all of my appts. with this guy, if I'm ever admitted to emergency care, hospital care, or whatever else in "Generic Health Network", they have everything they need at the click of a button.

    4. My PT is right down stairs from my doctor's office. This is good because she can relay any info to him in person if necessary.

    Okay, now for what I consider the negatives of seeing a PCP.

    1. All special procedures require him to refer me. Usually this is to a specialist within the "Generic Health Network". The referral may not be to the best specialist available. For instance, I had a PM visit that I'm not super thrilled with this week. I was referred there to consult for trigger point injections. The PM did not want to do them and sent me to a chiropractor. My tough break is the Chiropractor made me worse.

    2. 'Generic health Network' may not have the best surgeons in your area, you know?

    Overall I'm happy with my treatment. My doctor is a very nice, calm gentleman. He takes me serious with every issue I present him and has never once batted an eye at a problem. To me this is the most important factor - Dr/Patient trust.

    Hope this helps ;)
  • It helps a lot, CJ. Thanks for sharing your story and advice. I'm in a good position in a way, because I have one more month with the PM doctor. So today's appointment with the PCP won't have any urgency about pain treatment. Ideally, we'll hit it off and I can have my PM records transferred following my final appointment this month.

    It is always awkward walking in with five kids, to any doctor, to talk about my pain and especially about medication. I feel whiny and judged, even though no one's saying anything designed to make me feel that way.

    They either are very sympathetic ("oh you naive little mother of five!") or talk like I'm superwoman...not realizing that I'm there to talk about how my body feels, not the factors I can't control, like being busy.

    Also regarding the perception of someone walking in with a bunch of kids (I obviously don't have a nanny!), doctors seem unconvinced when I tell them about home exercise (given to my by a PT I've been to six times) I do for an abdominal diastasis, which may be causing all of this.

    I'm average weight (5'6, 135), do the exercises, stretch, and do headstands a few times a day. (I know many of you are in far worse shape in terms of your injuries and couldn't think about this...but for others, it works just like an inversion table but is free, and strengthens your core to boot.) So I describe the things I'm doing at home, the doctor listens skeptically, and then tells me I've got to start exercising to strengthen my abs. I usually say nothing because I don't want to come off as defensive. I'm so tired of biting my tongue and swallowing PM frustration.

    Anyway, your stories help, thank you. Now back to work!
  • That in many states...new laws are being passed that only PM Dr.s can prescribe opiates....Unless the PCP or Internist or Rheumy take continuing education and pass more strict regulation and licensing they are not able to do so...

    Again...this is different in each state....But over the next years...it is going to move in this direction nationwide as PM's are a speciality in chronic pain and medications...

    It actually makes sense as PCP is not a specialist in anything but broad based medicine...

    This is because of so many issues with prescription overdoses over the years are rising...

    So...certainly discuss this with the PCP and if they will be taking over your Pain Mgmt. long term...
  • I completely understand your frustrations. It sounds like we're both in similar physical shape, bad, but not horrible. Some of the stories on here make me glad I'm in the shape I am in.

    I too have experienced PM frustration. The one I saw this week didnt think I was having issues from disc bulge. I may not, but something is causing it. I may look in to a sports medicine doctor and get away from the PM stigma. I feel like both I've seen have somewhat judged me instantly or maybe not taken me as serious as I feel I should be.

    I can guarantee you if either of them had the back problems I have, they'd be searching for a solution too. It's very important I add I've never, ever asked for medication of any type. I'm seeking a treatment plan, not more medicine. If someday I feel I should be taking different medicine, I'll present that. For me medicine is not the answer right now.

    Please do follow up what you find out. I'm looking for a different road for myself. I may go see a neurologist and have him take a look at my films. The PM thinks the lumbar is MPS. I'm not buying it to be honest. I'm having way too much pain and other symptoms after having been jerked around on. If the disc is not causing the tension/guarding, something is.
  • I went this afternoon--a few things were interesting. A whole team came in. A nurse practitioner, a doctor (I believe to observe the NP), and a medical assistant to take notes. Unlike some people, I love having someone sit there and type away...makes me feel they're getting it all down and we won't have to repeat from visit to visit.

    I let them know about the wide range of medicine I'm taking now, and that I still feel my pain isn't well controlled. The dry needling, massage, headstands, kids standing on me while I lie on the floor, the PT...those are all treatments I can take care of on my own. I told her I'd like to reduce medication to 1) a single, strong, short-acting opiate; and 2) a single, strong, short-acting anti-inflammatory. I like being able to decide when I need medicine. I like being about to decide how much. I hate the routine, stigma, and expense of tightly controlled narcotics. I hate urine screens, I hate monthly appointments. I'd put up with them if the pain were markedly reduced, but it's not.

    I laid it all out and she referred to me another PM in their network. Ugh! Before we left the doctor's office, I noticed that my current PM doctor (the one who's moving his practice out of the state) is listed on the referral sheet as a preferred provider. So asked if I could get him to send my records to the new PCP instead of starting fresh. She agreed and said she'd be willing to do maintenance presciptions once I'm stablized off the long-acting meds.

    Promising, I think. I love the idea of having all seven of us (spouse and kids too) coordinated in one place. Instead of me monopolizing the whole family's time with my pain and various specialists.

    CJ, good luck to you. Lovetotravel, thanks for the insight--for all I know, I'm in one of the states where there are limitations on what a family practitioner can do in terms of pain management.

    Any other points of view or shared experience would be helpful.
  • I guess I'm a bit confused in that you mention you don't want to be on heavily controlled narcotics but Percocet is just as monitored as Oxycontin...They are both Schedule 2 medicines...

    And many Drs are less willing to prescribe the short acting medicines if you've already been on the long acting ones as they are more "abused"....

    Obviously this is not what you are doing...Just letting you know that when they hear that you want to go back to Percocet from Oxycontin and your pain is the same and not diminished...this could raise a red flag to them...

    To me...Taking one or two pills a day with Oxycontin is so much better and constant pain control than having to take Percocet as it only lasts a few hours....So you are chasing the pain all day long...

    Now...if your pain has lessened...than sure....going down in medication makes sense...But I assume you are asking for the same milligrams as the Oxy as it's the exact same opiate...

    I stopped Percocets a few years back as I didn't want to have acetaminophen in every dosage of my breakthrough medication...

    Just a few thoughts...

    I'm a bit confused on how you wrote things though...Is this PCP taking over your medication for good? Or did the refer you to a PM?

  • But only once stablized...so she initially referred me to a new pain management practice (since I'd told her my current PM was moving out of state) for the taper off the long-acting things I've been taking. When I realized they had an existing relationship with my current PM, I questioned whether it was necessary to get established at a new PM.

    So we left it that I would have this month's appointment with the current PM, request to taper off the big range of medicine I'm taking (Daypro, Parafon Forte, Tramadol, Oxycontin, and Oxycodone).

    The only time I remember feeling in control of my pain (not ever on top of the pain, but at least in a position to react to it) was with Vicodin 7.5 and Motrin 800. I took them a few days at a time when things were terrible, and took nothing on other days. In my memory, at least, I felt more in control of when and how I took medicine. As opposed to now, which is hundreds of different pills a month, two of which are round-the-clock.

    My preference would be to reduce it to, say, 120 pills total a month instead of closer to 400. But your points are all valid and are certainly the rationale behind the current regimine. Just not what I want long-term. We'll see where things stand later in the month.
  • That if you can get by with reducing it down to only taking Vicodin and Motrin....

    That's what I wasn't sure you were saying...but if your pain is not as high that you don't need the Oxycontin and Percocet.....than absolutely dropping back down is a good plan.

    Thanks for explaining more about how they said they would maintain you once you get to that particular level.

    Many Drs. are more comfortable only prescribing Vicdoin and not the other ones...

    Whatever works for you is the key!...I really hope that the Drs all work together to get you to where you want to be...

    Keep us posted:)
  • Thanks for the follow-up comments, LTT. My pain has not reduced in three years of treatment. I assume it's gone up, because I feel about the same or a little worse, even though I'm taking much more medication, and doing much more related treatments than I ever have before.

    My attitude at this point is that if so much medication is not helping, and I'm still spending every day preoccupied with pain, then it's not worth it.

    I realize my approach is a little turned around. It has crossed my mind that I've just not had a strong enough combination of medications. But I feel like the choice is more, more, more...or just lay off...and be in rotten pain either way.

    I also think I'm not good at pain management communication. I feel like I'm biting my tongue in every appointment, and I've never said "this isn't strong enough for my pain." At one point when I'd been prescribed Opana, I said I felt side effects, the doctor reduced me from twice per day to once per day and added a 5 mg. Vicodin per day. That was the month I remember feeling the worst. I took both medications more often than prescribed, ran out about five days early, and was asked for a urine sample at my appointment. If I'd told the doctor what I'd been feeling, I wouldn't have been in that uncomfortable position of testing negative for prescribed medication. The doctor was kind about it, but I knew I was in the wrong, and I was ashamed.

    Since then, after moving and needing to change doctors, I still haven't gotten over the impulse to not rock the boat. I'm not sure what rationale I'm using--maybe it's embarrassment over the whole pain situation, or maybe a fear of seeming drug seeking. Whatever it is, I'm not advocating well for myself and I'm still in so much pain every day.

    If my PM doctor had asked at some point, "is this helping enough?" I would have answered truthfully that it's not. But I feel like PMs expect people to want more and more drugs and I'm concerned about falling into that stereotype, especially as a relatively young healthy mother, when I see other people walking around absolutely hobbled by pain.

    I guess I'm holding out hope he will say something like that at the next appointment. My first choice would be to have enough relief to stop being preoccupied with pain. But otherwise my plan is to ask for reduced medications that can be managed between the PCP and me. The idea of having a big fat PM file that shows escalating medications is completely embarrassing to me.

    Don't know if this makes sense or if others have found themselves in the same situation. It doesn't seem totally logical as I write it out, but this is the best description I can give of the cycle and my rationale.

  • was that for me, my pain would be unbearable without medication. So it's not a situation that would be the same pain with/without medication.

    As I've written on other threads, Pain Mgmt. is about a building block approach. It's not about just one pain med or one procedure or treatment. It's about doing all the ones together that all add up to a dent in the pain to make it manageable each day.

    I do daily exercise (30-45 min),
    aqua therapy,
    injections when needed,
    TENS unit,
    counseling to help live with pain,
    take a muscle relaxer when needed,
    take opiate pain meds when needed,
    take a sleep medicine at night,
    eat all organic to reduce inflammation,
    don't smoke (never have) for those that do it can cause many issues with the spine and bones and obvious health issues

    These are just some of the things I do daily/weekly/monthly...I could never just do one thing...

    With all of this, my pain is at a 5-7 level each day.

    This is about as good as it gets for someone in chronic pain. I haven't had a pain free moment since right after my first surgery.

    So I can totally empathize that it's something that invades your thoughts all the time. That is why I added in counseling after my 3rd fusion surgery to help work out all the emotions.

    It's good that you were honest with your Dr. when you were having trouble and ended up taking more medication than prescribed....

    Is that something that you are worried about now as well and another reason you want to get off any opiates?

    I guess I don't understand the "embarassing" part with your med files....Who would see this but other Drs?

    In your personal life...it's best to only have one person...like your spouse, know what medications you take. I never share my medical details with anyone. Of course my friends know I have chronic pain...but we don't go over medications.

    So...I guess I am a bit confused because on one hand you say you need MORE pain control....and then on the other you are going to request you get off anything strong and only take Vicodin when needed..

    The part I am worried for you is, if you had trouble before....if you only have Vicodin....prescribed 4-6 a day....and then your pain goes skyrocketing....the answer will not be taking more than prescribed again...that will only cause more issues.

    Also to think about, if you request less medication...the Dr. will think it's because you are having less pain. Otherwise it won't make sense to him. And then if you do this plan...and then have terrible pain, then you have to go back and request higher pain meds again which will make it look "fishy" that your pain isn't as you say it is...

    Obviously as I said....if you can be comfortable and have a decent pain level with only Vicodin a few a day...than that is wonderful and no reason to not do this.

    But it just seems that you are saying you have bad pain....but just don't want to deal with the issues of pain meds.

    As I mentioned...Vicodin is just as controlled in that it can require a pain contract and urine tests and pill counts. So you won't be lessening those particular issues.

    I know you say it doesn't sound rational...but a Dr. is going to expect you to make rational decisions and have a reason why you need less pain medicine. And that reason should be less pain.

    Unless as I wrote above, you are worried about your taking more than prescribed and not being in control with them...Than I would still be honest with them about how to deal with this. A spouse could handle the medication and give to you when needed.

    Anyway....just some of my thoughts....and hope that you can work with the Drs on getting what you need...

    Keep us posted.
  • You hit on it there. I don't know what I'll feel like with fewer medications, and don't know how much the current medications are helping. My pain is as low as a 3 when I've been taking it easy, been to PT, had a massage and a hot bath...and as high as 9. Big fluctuations in spite of taking medications, including long-acting ones, as prescribed.

    The time I described above is the only time I've run out early by not following directions. I'm not worried about repeating that. But am worried that this huge investment of effort, thought, time, and money hasn't made pain more livable.

    In an earlier string, I described the multi-faceted approach I've taken: PT; home exercise and stretching twice per day; massage; acupuncture; biofeedback; on and on and on.

    Can't imagine I'm alone in not liking the idea of having a great big medical file in the absence of a serious accident or illness. But no, I don't fear that it's public. I hate the idea of being a chronic patient. (That feeling, at least, is one I know most people here share!)

    Your reaction is helpful to read. Especially if it reflects the thoughts my PM doctor might have at this month's appointment.

    This is the long and the short of it: I don't feel better. I've engaged in this process earnestly for more than three years, to little effect. So I need to find a way to feel more in control of my pain, and less the product of a complicated system that hasn't worked for me.

  • Still not sure how I'm going to frame the final PM discussion. Feeling a little unsure of myself and the best-case-scenario given the feedback I've gotten here. I think I can only lay it out for him the way I've described in these posts, then be prepared for a similar reaction.

    Also have an appointment next week with my (fantastic) physical therapist for more dry needling. For those of you who haven't had it done, let me share my experience: it's the most sickening pain during the procedure and for a day afterward, just as bad as labor for me, but a great relief two days later. The only drawback (aside from not being covered by my insurance through this provider) is that it's limited to the single area of focus described on the referral; in my case, that's the right SI joint. And unless I book a double appointment (which would be $350 out of pocket), there's no time left over for other manipulations. Actually, there is another drawback: husband and kids have to drop me off and wait in the car for 75 minutes so he can work remotely while I'm inside and then I can take him straight to his train...no kids allowed in the office.

    Going to hold off on asking for another chiropractic referral based on what I've read of others' experiences and my own back's lukewarm response in the past.

    The medication issue will go in one of a few directions depending on next week's PM appointment:

    1. Maintain the status quo (many medications, yoyo pain, but few side effects)

    2. Cut back to one strong opiate and one strong anti-inflammatory taken as-needed instead of round-the-clock (who knows if it's enough and whether I'd regret the request in short order)

    3. Referral to another pain management doc (starting fresh would be an enormous hassle, which I truly dread, but would give a new set of eyes on the overall situation and my MRIs and treatment records)

    4. Or some solution I haven't thought of yet.
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