A Discussion about the Pain
Management in a Primary Care Office
A single tablet combining
ibuprofen plus a high-dose H2-receptor antagonist (H2RA)
such as famotidine may decrease ibuprofen-induced ulcer disease and improve
patient compliance, according to a study presented at PAINWeek 2012.
All the literature on nonsteroidal
anti-inflammatory drugs (NSAIDs) is reviewed. When dealing with the pain of osteoarthritis (OA), rheumatoid arthritis (RA), and chronic pain the academic doctors emphasize using NSAIDs (Ibuprofen and its cousins). When a patient
says I have gastric problem with NSAIDs, we are suppose to say OK so take
Tylenol. The patient says, "I have come to
you only after trying all that. Besides, do not mention to me about Prozac, Lexapro
and Wellbutrin. I am saying I have anxiety too and I can't sleep due to the pain and
anxiety. But doctors keep pushing antidepressants on me. I am not depressed.
The only thing that works for me is Lortab and Xanax."
There is another option! Ibuprofen
with an acid inhibitor. Patients like it and “compliance will increase.” I feel like saying forget
about compliance, we have first see if patient agrees to Ibuprofen and Paxil.
We have been told that most of
the Lortab of the world is consumed in
Florida. It is produced in many parts
of the world including China and India. When I went to India, I wanted to know
how commonly it is used. Most people that I happen to meet were doctors. They
told me, it is not allowed to be sold in India. I talked to a pharmaceutical
company to check on it. They said the same thing.
I went to several pain management Continuous Medical Education (CME) conferences. What we learned was that in order
to prescribe a medication like Lortab, a physician has to have “ proper
documentation” besides many more rules like pill count, urine drug testing, and an MRI. Each activity is costly either to patient or the doctor. Proper
documentation means filling up and keeping records which includes 10 or more
different forms. That is all for one disease “Chronic Pain.” That means one
has to have so much staff and time to do it all. No wonder the cost of taking care
of only this one symptom is so high. Patients end up paying for it.
Besides that, one has to worry about drug diversion, early prescriptions, polypharmacy and more. Physician have to have an eye like a detective, police
officer, and DEA agent. All for one symptom - pain. (What about keeping such elaborate records on other 100 diseases like Diabetes, High Cholestrol, Heart Attack, Asthma, Infections, Seizure disorder.) The easiest way out of this mess
adopted by many is to not prescribe narcotics. Doctors who work for a salary are the first ones to jump on it and declare how clean they are. Patients may
cry or raise hell, it does not matter, they won't get the narcotics. Pain management specialists are not an option for everyone In the past few years, pain management doctor are not accessible to certain group of patients which include the poorest of our society. Examples are those patients who are on Medicaid or who have no insurance. Here's another option now. Take Ibuprofen or Ibuprofen with Zantac.
The way I see it is either you
can spend time and resources in keeping good records or in direct contact and spending
quality time with patient. Most in our field will say we can do both, but I believe we are lying to
ourselves and with others a lot in medicine.
The best way to ease the burden
on the subject of prescriptions of narcotics in my view is that either allow
prescribing of narcotics by only pain management clinics in Florida or give
them a clear quota that you will be able to prescribe narcotics for no more
than 60- 90 days worth narcotic per patient per year. Up to this level of
prescribing, only professional bodies will be able to monitor the level of
appropriate and good medical reasons and it will not constitute a criminal
activity prima fascia. Beyond this, everyone is expected to be treated by a Pain Management Specialist.
Chronic pain is the pain which
last 90 days or more. The above idea covers all acute conditions and not the
chronic pain conditions. Then we will stop seeing commotions in primary care
offices. It is a fact that 40% of patients who have Medicaid are not accepted
by physicians in Florida. A part of it is the impression that many of such
patients come and show desperation due
to chronic pain. They present as difficult patients. Physician do not have
energy to handle it at the current reimbursement rate.