"Pain" Management

Pain management is an important part of podiatric practice. You might even say this is the most significant part of our practice. We've all heard the statistic that pain is the most common complaint that brings patients to the doctor. Not a day goes by where I'm not managing some aspect of my patients' pain. Whether it's padding, taping, orthotics, injections, referrals, or surgery, we spend the majority of our time attempting to decrease pain. The other method that I haven't mentioned – which causes more headaches than almost any other treatment – is prescription pain management.

Jarrod Shapiro, DPM
Joined Mountain View Medical
& Surgical Associates of
Madras, Oregon July 2008

Several weeks ago, I had a new patient with a non-displaced three-day-old 5th metatarsal avulsion fracture. She'd been seen in the ER the day prior and dispensed a cam walker, PRICE instructions, and an Rx for Vicodin. Does anyone leave the ER without a narcotic prescription? I wonder…. Anyway, I continued the same treatment, except I added crutches and NWB instructions. She followed up a few weeks later improved, but still in pain. I agreed to refill her Vicodin once. One week later, she calls the office saying her Vicodin was stolen from her purse. I'd have to be an idiot to believe that story! Of course, I refused her any new narcotic prescriptions, offering her Motrin. Her next appointment will be interesting!

How do YOU handle the inevitable narcotic seeker?

Here are some thoughts on the matter:

I'm not the most difficult doctor to fool into giving pain meds, mostly because I'm still naive enough to believe the best in people. I'm sure, given a few more years, I'll no longer believe what anyone tells me. Until that time, I'll get to know my patients as much as possible before prescribing medications (and especially before doing surgery). I make every attempt to ascertain the true level of their pain and treat it appropriately.

Don't forget there are many ways to treat pain. You might consider nonweightbearing, ice, elevation, massage, or topical medications like Biofreeze or capsaicin. You might also consider other prescription medications like Lidoderm patches, muscle relaxants, and anxiolytics. I regularly refer patients to physical therapy. And don't forget about referring patients either to a pain management specialist or back to their primary care doctor.

When I consent a patient for surgery, I spend considerable time discussing every aspect of their perioperative period, including pain management. As part of a comprehensive consent process, I include a written discussion on pain management (which they have to sign off on). I've included below an excerpt from my consent paperwork:

"Pain Management – Your physician will determine the postoperative pain management regimen and will take your requests into consideration, but he will make the final decision regarding the most appropriate prescriptions based on a full review of your medical history and circumstances. Be sure to alert your physician to any allergic or adverse reactions to any drugs in the past. Narcotic pain medication will be limited to a maximum of two months and may be discontinued prior to this time period as determined by your doctor. Any pain after this time period will be handled with non-narcotic methods."

I honestly don't know if this really works and dissuades those pain seekers. If anything, I’m at least covering myself from a medicolegal standpoint – hopefully. I don't think there's any perfect way of handling this issue. If there were, then my state would not require 7 CME credits per year of pain management education. In case you're interested, the AMA has a pain management online course that I found informative; www.ama-cmeonline.com/pain_mgmt. Until the golden age of medicine arrives and patients are no longer addicted to pain medication, I'll continue trying to weed out the addicts from the legitimate patients. What are your thoughts? How do you handle pain patients?

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Letter to the Editor
***Orthopedists – Friend or Foe?***

I have been in practice for about 23 years in the Boston area. It took some time to get a feeling for which Orthopedic Surgeons in our community I would be able to "work" with. I made it my business to attend Orthopedic Rounds and actually met some of these doctors face to face. It was a little awkward for me at the beginning but, with time, I felt more comfortable and developed good professional relationships with at least 6 Orthopedic Surgeons. Over the years, I have assisted two of these doctors in the O.R., doing Foot and Ankle cases. I have learned from them and they have learned from me. I have been asked to present cases at Rounds and also prepared lectures in topics such as Posterior Tibial Tendon Dysfunction. I also do receive referrals from them for orthotics, but also to tackle some surgical cases that they seem to feel I can do well. These have ranged from Austin Bunionectomies to Endoscopic Plantar Fascial releases. I have also asked one of the Orthopedic Surgeons to help me on a case where bone had to be harvested to be used as a graft. He did not hesitate and was extremely helpful to me. There are other Orthopedic Surgeons in the area that have not been as friendly to me and I just simply have very little contact with them. But, in general, with patience and investing time to attend Rounds and other meetings, I have had a very positive experience with Orthopedic Surgeons.

—George Ducach, DPM
Quincy, MA
[email protected]

Keep writing in with your comments. Best wishes.

Jarrod Shapiro, DPM
PRESENT New Docs Editor
[email protected]