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Medicine is a big topic here , but I am going to go out on a limb and claim many prescribing doctors are basing their prescribing on routine / historical information vs. individual evaluation. Let me defend this. I have been all over the US, prescribed many, many meds that deal with neurological and muscular pain. So when I was properly diagnosed and still on same meds I saw a pain management guy specializing in what I have, immediately said that is the wrong nerve med and muscle relaxer. Prescribed baclofen and nortriptyline, when I had been on amatriptyline and flexiril when I saw him (if remember right). Instantly my nerve pain was better controlled. So I asked him and he told me most doctors go through routine with nerve meds and muscle relaxers, start with one then move through them, but you had a spinal cord injury / central pain and in my experience and your evaluation these are going to work better on centralized pain. I even commented how baclofen, a muscle relaxer, helped my nerve pain so much and he responded how great of a med it was for the type of pain I have.
Most every other doctor just looked at what I had been on and said "lets try this" , but there was a lack of real thought process (or explanation of one) for what would work best. Even some of the current team of doctors tried meds that did not help, but there was always a thought process explained to why we were trying this specific one. There was no gabapentin, lyrica, cymbalta progression just for the sake of the progression and reasons were given why they stood less chance to work, this was not the case with less skilled doctors.
To be fair I was a complicated case, but I would speculate a large part of prescribing meds is guesswork and I would also speculate it does not have to be based on my comparison of doctors I have seen. I have been on baclofen and nortriptyline for almost two years, no change in my dose (other than lower it on my request). I do know guesswork is a part of it , but is that to large a part of it when nerve meds often take many weeks to see full benefit ? This is not to put down doctors, but more to bring up patients that could be going down a long road that really in the right hands is unnecessary.
I am interested in this from a opiod argument also, but I have little experience in it other than very well read and researched. One of my go to PM doctors that I follow believes DNA testing is the only way to properly prescribe without guess work , but that does not cover the nerve meds or muscle relaxers at this time I believe. Just interested to hear others thoughts on this as I have no solutions since some top doctors on my team did not know the exact one for my case that would work .