"Send 'em to the pain clinic!" When Patients Need Services That Don't Exist.

Once a time long, long ago, in a place far, far away, I worked in a neurosurgery department. PAs and NPs were used pretty much as mini-residents. We’d see patients after arrival at the clinic, talk to them and do a focused exam, and the go report to a surgeon. At that point the surgeon would go back into the room with the PA, ask a few unintelligible questions of the patient, offer the patient options that the patients completely didn’t understand, and then on the way out the door bark a few orders to the PA over their shoulder. And that was that.

Frequently the orders would relate to pain care. This clinic had a very strict stance on pain medication. Even for patients who had undergone extensive brain surgery including partial skull removal and related intracranial mayhem like maybe a week ago, little pain medication was given upon discharge. When patients would return in pain after having used their brief run of short-acting opioids, the PA would be told “send ‘em to the pain clinic!”

Although I never had the will to ask this of my supervising MD, my internal response was “exactly which pain clinic are your referring to?” In my setting, like in most, pain clinics where patients such as this can receive pain medication most commonly do not exist. It is rare for a pain clinic to take on prescribing of pain medication after surgery at the request of the surgical team.

Certainly this service SHOULD exist, but it almost always never does. So the PA in the clinic would try to reach out to the primary care provider to take on tapering of the medication, and would usually be met with “Let me get this straight PA Anderson. Your team just performed invasive and complicated brain surgery and now you want to dump the pain issue on ME?”

This was one of many services that are needed, but don’t exist. It doesn’t take much time practicing as a PA to run into such non-existent services, exposing some of the many giant gaps in care in our often crazy and poorly designed health care system.

Another sorely needed but seldom available service is tapering benzodiazepines in patients wanting or needing to stop taking this often troublesome medications. I now work in an Opioid Treatment Program (OTP, aka methadone clinic), working with patients attempting to stop their heroin or other aberrant opioid use by taking methadone or buprenorphine instead. As anyone who has worked in an OTP knows, benzodiazepines can be the bane OTPs and their patients. Benzodiazepines and opioids are always a potentially dangerous mix, which is why there is now a black box warning regarding prescribing benzodiazepines for patients taking opioids.

Most of the patients I work with who take benzodiazepines struggle with success in treatment, and many of them desperately want to stop taking them. That’s one of the difficulties about taking benzodiazepines, that they are so hard to stop taking. Patients can become very sick in benzodiazepine withdrawal, with an increased risk of having seizures. I’ve known many patients who have had terrible things happen to them when trying to stop taking them, including seizures, nasty falls, and accompanying trauma including fractures and facial injuries.

One of the problems is that patients who often start with a nonchalant benzodiazepine prescription end up having prescribing terminated and then taking them on the street, making it tougher to taper. OTPs don’t want to take it on, because that would entail prescribing them. Primary care providers and psychiatrists are seldom willing to take on such a taper for the same reason. Yet another factor causing reluctance of almost all providers to handle these tapers is that there is little evidence-based guidance about how to taper people from these medications.

I know there are many more unmet needs for our patients. It can really make caring for complex patients difficult. I’d love to hear from you about what services are needed, but not available, in your settings. Drop me an email at j.eddy.anderson@gmail.com

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