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Do prescribing doctors follow evaluation , experience, routine or what they were taught ??

itsautonomicitsautonomic LouisianaPosts: 2,561
edited 08/02/2017 - 3:07 PM in Chronic Pain

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 .

Do your due dilegence, trust you know your body and question everything if it does not fit. Advocate for yourself and you will be suprised what will be revealed trusting your body and instinct.


  • AkiraAAkira Redlands, CAPosts: 82

    My case is not near complicated as yours or others, but before I go into the meds conversation I will discuss my spine evaluation history.  On 8/16 I went to the ER due to my severe vise grip pain throughout my back and chest.  Numerous tests at the hospital ER, afterwards told by the discharging doctor that it's a muscle pull and follow up with my PCP.  Met with the PCP within the week and was told that it's a muscle pull, go get a massage, take some advils and should be better in 2-3 weeks.  I could not get an appointment with my PCP unless I waited 6 weeks.  I changed PCP and the new doctor explained to me that it's a muscle pull, but prescribed me flexril and hydrocodone.  Upon my constant badgering and finally pleading to my PCP for a referral to a spine doctor I was able to proceed with an x-ray in the spine doctor's office and a referral for an MRI.  MRI completed and with disc in hand at the spine doctor's office on 12/16 with the radiology report.  I was told that it's too late to do anything about my T-8 fracture since it has been over 3 months and already healed.  Told to get a referral for a PM doctor from my PCP!

    Within my HMO insurance group I researched my list of PM doctors and it took more badgering and pleading to refer me to the PM doctor of my choice.  This was not easy, as doctors (I've found out) play the game you scratch my back I'll scratch your back, meaning they have an unmentioned loyalty to their choice of doctor or doctors on whom they refer their patients to.

    Finally got to see the PM doctor of my choice who is board certified with 20+ years in the field.  First day of initial consultation, I was prescribed gabapentin for the nerve pain, oxycodone for the back pain, and diclofenac for arthritis.  Since then upon my visits with the PM doctor he has recommended other number of drugs to ease my nerve pain, but I just couldn't handle the side effects.  We have not discussed the opioid medicine other than the usage increasing from 3 pills daily to 4.  Fortunate for me the PM doctor isn't apprehensive when it comes to meds, is that good or bad I don't know.  

    To be on topic Aaron, I believe it's both.  Historical evaluation from his years of dealing with spine patients and my individual evaluation of the intercostal nerve pain.  He is requesting another MRI before he proceeds to the 2nd RFA or hopefully a new medicine maybe?

    Sorry for going off the "medicine" topic.  Low number pain day to all.

  • memerainboltmemerainbolt IndianaPosts: 6,357


    Every doctor I ever went to regarding my back was the "let's try this". Or let's try a different strength.
    Except the PM I have now. On my first visit he did the Personalized Gene Drug Therapy Interaction test and found that none of them were working. 
    I have mentioned this test on the forum before. It saves a lot of time, money and pain for the patient. But why don't doctors do this test more often?

    Veritas-Health Forum Moderator
    Please read my  Medical History
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  • itsautonomicitsautonomic LouisianaPosts: 2,561

    Sandra, I think we both have read practical pain management writings if I am not mistaken and the editor who is a well known PM is a huge advocate of the testing.  Do you think it was more expensive to try the meds/many visits vs. get testing initially and know what won't work?

    I understand guesswork is part of pain management , but I also know pharmaceutical reps act like lobbyists for their own meds and if you have a dr who is not well educated in the drug or takes the time to know everything about it there could be delay in relief.  There is guessing and there is educated guessing in my opinion.  It's a frustrating situation that I personally don't understand completely , but think could be way better.  Again , I am pulling from personal experience at how easy it was for one dr to understand the rationale of meds when many others just looked at trial and error.  The try this , it works for some people isn't enough for me unless I am desperate.  Talk to me, tell me more than that as to why it stands a chance to work best

    Outside of pain my brother (mental issues) often has to endure weeks of side effects to only realize it doesn't help when in system for depression/bipolar.  The constant run through of meds takes its toll on his mind.  But similar situation where saw right dr and said no, no lithium is what you need and it's held his mania at bay for over ten years but that was after several meds from other Drs.I have read DNA testing for anti depressants is being looked at next .  

    On a common sense , not understanding it all view it seems such a simple choice if you can test to see what med works best, by all means test.  Need to learn more for now

    Do your due dilegence, trust you know your body and question everything if it does not fit. Advocate for yourself and you will be suprised what will be revealed trusting your body and instinct.
  • memerainboltmemerainbolt IndianaPosts: 6,357

    I honestly don't know how much the test is, my insurance covered it. But I would have paid for it, to me it would have been worth it.
    You can't put a price on pain that is not managed. I went through years of pain, countless doctors, injections, different pain meds for essentially nothing. Why put patients through that? 

    I'm always trying to get this information out to members, maybe I need to do another discussion on this for the new members.
    A patient should not have to ask for this test, but they need to.

    Veritas-Health Forum Moderator
    Please read my  Medical History
  • Hi Aaron
    You know I have taken pain meds for now going on over 20 years that statement makes me sick to my stomach. Anyways I have a list of all types of meds that have been thrown at me "Let's try this" I always felt it was a guess and more than not to avoid giving pain meds. I am part of that though I requested to try tons of other meds including "  " which I later found out the doctor was not trained to prescribe that I had a life threatening reaction to it. For instance Celebrex how stupid was I to let them order me to take it three times when the side effects were skin bleeding , breathing etc. Their comment is you don't always have the same side effects and aspirin has side effects. I know I should of stood up for myself but that was when I believed you do whatever they tell you.
    I am going to request that drug test Sandra talks about if it was available and they just did not use it I will let them know how I feel about that. It maybe an insurance thing but what a waste of money and health plus quality of life. Think about how many people out there have had the experience I have if they took the test all the damage avoided to the body and mind from so many meds. 
    I only bring this up because to me it is a huge part of why doctor's struggle with knowing how to deal with pain. I just watched a show on the minimal training they get in school for Pain Management. 
    We have discussed if they would just use what ever medication that was right and get the pain under control not only would people be able to pursue all the therapy etc. available to me a much better route to go. 
    Steroids is a major one to me given out like the miracle drug and so much damage left over.
    Thanks Sherri

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  • Sorry the drug I meant to put that left me damage was Suboxone my PC doctor was shocked that it was given to me by a GP.

  • regarding the genetic testing...my pain mgmt. doctor last year did it for me and stated that it would not be out of pocket if my insurance did not cover it

    my insurance denied it stating it was experimental...I never was billed for it, but I checked the claim, and the bill was around $1700 for some lab out of California

  • AkiraAAkira Redlands, CAPosts: 82

    We should have statistical numbers from the pharmaceutical companies for every drug they develop for patients.  Numbers dictating how many people have to take it before it truly works for the prescribed patient.  If 100 people took the drug, how many out of that 100 receive real benefits?  Also what are the % of side effects?  Is it 5 out of 100 or 20 out of 100.  And information on how long you have to take the drug before most people get the benefits?  Sine we don't have these numbers, we are the guinea pigs as we are prescribed the drugs, hopefully from a real knowledgeable doctor that has done extensive research instead of just listening to the pharma sales person who brings in the free lunch for the medical office.

  •  Insurance companies want to start off with the least expensive drug, preferably generic, and go from there. This was done on a pretext of saving claimants money. Of course, this is one of the factors determining which meds are used. The CDC now wants doctors to prescribe the lowest dose possible before transitioning to stronger pain medication. I also agree that docs use a trial and error approach with medications as well. It was a long time before I was finally given Baclofen...I went through Skelaxin, Flexeril, and Zanaflex before getting to the best one, in my opinion. As far as training, last I heard was medical schools allot one day to teach pain management. I hope it's not the case since 1/3 of us suffer with chronic pain (U.S.)
    Ol' Spiney..Micro-D L4-L5, TLIF L4-S1 -post op central HNP L4-S1,stenosis, retrolisthesis, EF, facet arthropathy, lumbar& cervical DDD. FBSS- Medtronic pain pump & SCS
  • Max_LeeMax_Lee New York, United StatesPosts: 389

    They do have the testing available for antidepressants now! My psych actually suggested it and it would have saved so much time had it been done sooner. Surprisingly, Medicaid did cover it.

    @Hope3 I totally hear you on the celebrex and steroids. While they are good for many things, they do not come without some pretty serious side effects - especially NSAIDs as they can cause some really nasty lasting effects. They are pretty good for some things - but they seem a bit overused. It sometimes does seem like providers are trying to avoid prescribing pain meds and will use anything else. It never mattered if I ate or not with NSAIDs after a couple months of being on them in the beginning, they did not agree with my stomach at all and the longer I took them, the sicker I'd get afterwards. I lost a lot of weight because of it. Sucks, because Motrin was my best friend for cramps before.

    Sometimes it does feel like providers are playing darts when figuring out which medications to prescribe. It can feel like being a guinea pig. Not using this testing seems like such a waste, it would save so much time and energy on both sides.

     "The loneliest people are the kindest. The saddest people smile the
    brightest. The most damaged people are the wisest. All because they do
    not wish to see anyone else suffer the way they do.''-Anonymous

    My Story: https://www.spine-health.com/forum/discussion/90688/pain/neck-pain-cervical/help#latest

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