LonguylandPA Posted June 13, 2018 Share Posted June 13, 2018 Sort of a follow up post.. I just wanted some assurance or any criticism to my current job role. I am swimming so far and so far so good.. but who knows I was hired out of school (3 months now) at a spine & ortho practice under the guise that "theres a small amount of post surgery patients on chronic pain management" however its more like 90% of the patients. Most patients are on around 90-120mg Morphine equivalent dosing a day. and they are all previous surgery cases. These are patients that have been on opioid therapy under the orthopedic surgeon for 2-10 years Before I started working: antineuropathics like lyrics and cymbalta have not been utilized. there has been no urine testing in 2-3 years. some patients charts are pretty much the same from month after month (besides getting updated imaging/EMGS) I am now implementing Gradual dose reduction with attempts to switch patients from oxycodone/vicadin instant releases over to Tramadol, or MS Contin, Nucynta, Adding lyrics/uptitrating gabapentin from previous doses of 800mg/day towards 1600mg/day. adding pain creams, switching to NSAIDS with famatodine for GI protection, discontinuing benzodiazepines and adding nonbenzo anxiety meds if the situation calls for it. Hell, I'm even recommending turmeric/curcumin to some of my arthritis patients because of good study results ive read a good amount of the patients that are on high doses (120mg/day) resist my reduction attempts to 90mg a day, and with them, I only lower them by 2 pills/month so I can at least show something. I am now also getting urine tests on a good amount of patients with 50% pain med reduction if positive results (with solid documentation of a marked and final warning before discharge) I see about 10-20 patients in an 8 hour period. Its not stressful. What is stressful is the lack of guidance from my surgeon. He really focuses on the surgery and doesnt really educate me or have any advice on the pain management... There is another PMR MD alongside me however he isnt too knowledgable, and basically mirrors whatever the surgeon does. A question of mine is also: I am working under a ortho surgeon but I am fulfilling more of a pain management role as a PA. is this allowed? I know pain management is considered its own field Link to comment Share on other sites More sharing options...
mgriffiths Posted June 13, 2018 Share Posted June 13, 2018 Simple answer is that most providers in primary care are essentially performing pain management - so not a problem for you to be performing. Due to a new law, I've got 42 patients on my schedule for controlled substance refills - and many are on narcotics. It is my job to handle their refills, wean, etc. as I see fit - there is one "pain clinic" in the area that doesn't accept medicare/medicaid patients and for commercial patients the wait list is at 14 months right now - ridiculous. So, from a legal perspective it is totally legal, but not ideal. Other than the MASSIVE bonus I'm making on these days (~$900+ per day) seeing 40+ patients in a single day sucks the life out of me. Link to comment Share on other sites More sharing options...
krisephillips Posted June 13, 2018 Share Posted June 13, 2018 My first job out of school was in pain management. It was definitely a learning experience and taught me the business side of medicine that I was not exposed to during training. I would see 30-34 patients a day on average (private insurance, Medicaid/care, BWC) and yes, it did suck the life from me. It was a block/procedure shop (spinal cord stimulators, intrathecal pump placements) and that was all the attendings wanted to do and I was left to do the medical management portion. Your patient volume is good at 10-20 per day and allows you the time for proper assessment/med management. Keep with detailed charting, testing, drug screening as you have already begun. Get to know the local drug task force agents as they can keep you informed of problem patients/concerns/assistance to keep you within state laws. Link to comment Share on other sites More sharing options...
camoman1234 Posted June 13, 2018 Share Posted June 13, 2018 14 hours ago, LonguylandPA said: Sort of a follow up post.. I just wanted some assurance or any criticism to my current job role. I am swimming so far and so far so good.. but who knows I was hired out of school (3 months now) at a spine & ortho practice under the guise that "theres a small amount of post surgery patients on chronic pain management" however its more like 90% of the patients. Most patients are on around 90-120mg Morphine equivalent dosing a day. and they are all previous surgery cases. These are patients that have been on opioid therapy under the orthopedic surgeon for 2-10 years Before I started working: antineuropathics like lyrics and cymbalta have not been utilized. there has been no urine testing in 2-3 years. some patients charts are pretty much the same from month after month (besides getting updated imaging/EMGS) I am now implementing Gradual dose reduction with attempts to switch patients from oxycodone/vicadin instant releases over to Tramadol, or MS Contin, Nucynta, Adding lyrics/uptitrating gabapentin from previous doses of 800mg/day towards 1600mg/day. adding pain creams, switching to NSAIDS with famatodine for GI protection, discontinuing benzodiazepines and adding nonbenzo anxiety meds if the situation calls for it. Hell, I'm even recommending turmeric/curcumin to some of my arthritis patients because of good study results ive read a good amount of the patients that are on high doses (120mg/day) resist my reduction attempts to 90mg a day, and with them, I only lower them by 2 pills/month so I can at least show something. I am now also getting urine tests on a good amount of patients with 50% pain med reduction if positive results (with solid documentation of a marked and final warning before discharge) I see about 10-20 patients in an 8 hour period. Its not stressful. What is stressful is the lack of guidance from my surgeon. He really focuses on the surgery and doesnt really educate me or have any advice on the pain management... There is another PMR MD alongside me however he isnt too knowledgable, and basically mirrors whatever the surgeon does. A question of mine is also: I am working under a ortho surgeon but I am fulfilling more of a pain management role as a PA. is this allowed? I know pain management is considered its own field First question: what do you mean by 50% pain med reduction if positive results? Positive for the medication or positive for elicit drug use? If it is for elicit drug you I can them right there on the spot (after I get conformation from the lab by GC/MS) and there is NO/ZERO pain medication reduction. They do not need to be reduced as they are using other elicit drugs to help cover them, they broke their pain contract, it is ILLEGAL and they are most likely selling some of those pills. Second question: "Hell, I'm even recommending turmeric/curcumin to some of my arthritis patients because of good study results ive read." Why are provider so reluctant to do natural alternatives for patients? Why are so many provider of adding/using these great medications, start low and go slow. I have never had any patients have reactions if you use the start low and go slow method (with natural medications, herbs, vitamins). You are doing the right think IMO, but I wish more providers would research more herbs/natural therapies for chronic pain and try them. I am not sure what people are so scared of? All medications/herbs/vitamins all have side effects, just have to warn, watch, educate (both yourself and the patient). Have to you using bracing for patients? That is just another tool for you to utilize that does more for most people. Do you do nerve blocks/trigger points? Link to comment Share on other sites More sharing options...
PsychiatricPA Posted June 13, 2018 Share Posted June 13, 2018 9 hours ago, krisephillips said: Get to know the local drug task force agents as they can keep you informed of problem patients/concerns/assistance to keep you within state laws. How do I get to know them? Curious to know how they can help me... Link to comment Share on other sites More sharing options...
LonguylandPA Posted June 15, 2018 Author Share Posted June 15, 2018 On 6/13/2018 at 10:06 AM, krisephillips said: My first job out of school was in pain management. It was definitely a learning experience and taught me the business side of medicine that I was not exposed to during training. I would see 30-34 patients a day on average (private insurance, Medicaid/care, BWC) and yes, it did suck the life from me. It was a block/procedure shop (spinal cord stimulators, intrathecal pump placements) and that was all the attendings wanted to do and I was left to do the medical management portion. Your patient volume is good at 10-20 per day and allows you the time for proper assessment/med management. Keep with detailed charting, testing, drug screening as you have already begun. Get to know the local drug task force agents as they can keep you informed of problem patients/concerns/assistance to keep you within state laws. Follow up Q: if I am actively weaning down opioids, even if its just 2 out of 90 pills less per month at a time, thats still considered progress right? I know that the Gradual dose reduction guidelines sort of say for a 10-20% reduction PER WEEK which I find very unrealistic for a patient thats been on opioids for years and doesnt want to give them up note: this is for a patient who I believe is on a high proportion of meds compared to their pathological findings/physical/personality/history Link to comment Share on other sites More sharing options...
thinkertdm Posted June 15, 2018 Share Posted June 15, 2018 14 hours ago, LonguylandPA said: Follow up Q: if I am actively weaning down opioids, even if its just 2 out of 90 pills less per month at a time, thats still considered progress right? Its progress if the patients pain is controlled on a safer (less cognitively impairing, addictive) substance. The tenets of medicine remain the same, whether it is opioids or hypertension: use the minimum of the substance to achieve the maximum effect. I am dealing with providers who have been prescribing ambien to 70 and 80 year olds for decades. No discussion of sleep issues, and at each visit "sleep- well controlled. continue with ambien 10 mg". This is not appropriate. At all. so now I have grumpy patients because I'm taking away their goodies. So the same with you. Identify the problem. Review what has been tried. Review what the patient is doing. Review lab work. Think to yourself, am I hitting with a sledgehammer what a flyswatter will do? Remember, opioids are very useful, but also very dangerous. Link to comment Share on other sites More sharing options...
LonguylandPA Posted June 15, 2018 Author Share Posted June 15, 2018 35 minutes ago, thinkertdm said: I am dealing with providers who have been prescribing ambien to 70 and 80 year olds for decades. No discussion of sleep issues, and at each visit "sleep- well controlled. continue with ambien 10 mg". This is not appropriate. At all. so now I have grumpy patients because I'm taking away their goodies. This pretty much explains my situation I also have patients on ambien from an ORTHO office... Whats your go to method of weaning off ambient assuming starting from 10mg ohs with monthly visits Link to comment Share on other sites More sharing options...
Guest JMPA Posted June 16, 2018 Share Posted June 16, 2018 watch your tramadol use, it has many interactions, does not mix well with muscle relaxers, don't forget the cumulative effects of tylenol with NSAID ( a very effective regime), ISTOP/UA/hands on evaluations with good charting should be enough to cover all bases Ramble complete Link to comment Share on other sites More sharing options...
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