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Old 02-17-2011, 09:27 PM
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Default Pain Management-How do you change doctors?

I'm trying to get a second opinion on my treatment and options from my pain management doctor. Every time I call another pain manager, they put me on hold and come back and tell me to send my records. They will look at them and call me to make an appointment. I had one come back and tell me they only treat acute pain. What does that even mean?

Is this normal? They ask why I need the appointment and when I tell them they say "Uh-huh, well just send your information."

This is the first time I have seen a pain management doctor. Anytime a doctor wants to do a procedue, I would normally get several opinions. Have I been black listed in some way or is there a law that says you can't change PM doctors?

Thanks.
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Old 02-17-2011, 10:57 PM
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Default In my case

I was Worker's Compensation for my low back so I had to have my Nurse Case Manager call the office back after I made the initial call and they had to get the records to the office and then the office would decide if they would see me (this was in CA). I had no problems in CA being seen or switching doctors.

Then I moved to Florida for a year and a half. Before I moved I called numerous PM offices and they all said what you were told "send your records" and I had bought a house in Fla as my Mom was sick at the time and was moving never daring to think it would be a problem to obtain PM care out of state. Out of 200 offices only one PM in Tampa would see me with my CA Worker's Comp and all the rest said "no" many after I sent my records in or my Nurse Case Manager did as they "didn't take CA WC" was the big message.

Eventually the PM in Tampa tried to manipulate me into doing whatever he wanted re PM because he knew no one else would see me and even made a comment to that effect. Fortunately my husband had gotten a new job back in CA so we moved back.

When I returned I just called a PM in San Diego that I wanted to see and his office asked that my Nurse Case Manager call and everything was set up after that. So don't know if your insurance has anything to do with it or if perhaps it might be a good idea to get a referral from your Primary Treating doctor (Primary Care or Orthopedic or Neurologist or Neurosurgeon).

Last edited by Maria; 02-17-2011 at 11:01 PM.
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Old 02-18-2011, 12:29 AM
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Well, I know it can't be the insurance. I got their names off of our provider list after my Internal Med doc gave me the names. I have an appt with him next week and will ask if he can help in any way. I just don't understand why it is so difficult. I'm going to call our insurance tomorrow and talk to them about a case manager. I think they have some kind of program.
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Old 02-18-2011, 03:13 AM
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I am in California with no attachments to my treatment . My primary care referred me to a friend of his in pm. Otherwise i could not get into his practice. I really knew nothing of pm before that. I went to see him and he prescribed meds and had me up what i was taking and i felt like a new person in a day and was so happy. WHen he heard who my surgeon was he bluntly said i dont work with him. So some apts were good and some he was not so friendly. Well my spine surgeon always does his own ESI. Apparantly the pm doc was mad at that everytime i reported having any and when i had the thoracic discography and he had not done it that was the last straw. He emailed me a nasty letter. I sent one back (nice one) and then he apoligized. But told me another pm doc who should see me

New doc is associated with my spine surgeon. On my way to my apt like 10 minutes before i get a call from someone at her office. They wanted to know why i thought i could go to 2 docs, or why was he not seeing me anymore. All kinds of questions. It was a strange first meeting. She sounded like she did not like my spine surgeon either and said that is how they make their money and she was going to see if the first doc would take me back.
NIce to feel wanted!!!!
I am still with doctor #2. I am having injections the day after i see her with my spine surgeon and i don't know if i should even mention them.
so i am kind of afraid to change if i heard of someone great. I'd say try to get a referral from a doc as your primary care , seems to go smoother that way.
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Old 02-18-2011, 05:50 PM
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I had no problems changing doctors but then again, I didn't give any history over the phone, just made an appointment stating my gp thought I needed a pm.

During first appointment, I gave him my history- end of story.

Now having said that, I'm sure the other shoe will fall because I remember saying the same thing about my US ADR surgery being approved by my ins co only to have the plug pulled with only 1 week to go.


Dale
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Old 02-18-2011, 08:47 PM
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One of my previous CA PM providers did get sort of upset because I chose to get my ESIs with an anesthesiologist that didn't work with the PM practice. My current PM told me outright that's what PMs make their $ off of not the office visits for scripts so the $ is in the injections (ESIs and other).

Now WC no longer authorizes ESIs for me so I'm hoping this PM will continue to see me just for prescription refill. I normally see him every 3 months just for scripts now and I travel several hours to see him as I have a very good rapport with this PM of the last 6 years.

Good luck getting someone to see you. May take a while. I wouldn't want to waste an insurance copay if I were paying out of pocket or my time sending records back so I personally do inquire about the practice and whether the PM prescribes medicines, does injections and so forth. In the past I wouldn't have wanted to go to one that didn't prescribe medicine or do injections (ESIs). Not saying you have to tell your whole history over the phone but in order not to waste your time you might want to ask some routine questions of your own regarding the practice to make sure it's what you're looking for before agreeing to send records. I have usually asked to speak the office manager about this and never had a problem with getting information about the practice.

I got a Nurse Case Manager when my 2nd spine surgery failed and I was deeply depressed and verbalizing some pretty "deep" thoughts/emotions that were "red flags" to bump up my level of care and case management. The insurance companies don't usually pay for a case manager unless it's deemed necessary as it's an added expense to them. Since I decided not to have another surgery after a number of years my Nurse Case Manager was pulled.

Last edited by Maria; 02-18-2011 at 08:53 PM.
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Old 06-07-2012, 08:27 AM
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Default Changing pain doctors---Threats pain doctors use

I had the worst, most frustrating experience, that led me to fire a pain doctor, for many reasons, including his not even trying to treat my neuropathy.
His tactics should be considered or made illegal.
I had gone to this pain doctor's office for over 4 years, and I never once even flunked a surprise drug test.
I was the perfect patient. Always paid on time, etc.
I had been going to his office because I have a serious illness that causes a great deal of physical pain.
Here is my experience from hell.
This happened after my going to his pain office for over 4 years.
In retaliation for my telling his new office manager named Danny (who I never met in person) that I was seeking a second opinion from another doctor, and that I wanted to hire a board certified neurologist to deal with my newly developed neuropathy, the doctor had his office manager threaten to label me in my medical records as a "drug shopper!!!!"
I have a MAJOR, potentially fatal chronic illness that was diagnosed a decade ago.
He had me on opiates.
But the doctor made no attempt to help with the neuropathy, which is not treated with opiates, but with other drugs.
When I went to this guy's pain office, I rarely ever got to see the pain doctor, himself---He was usually never there.
Instead, in my over 4 years of going there, at 98 percent of my monthly visits, I just got passed off onto one his seemingly endless series of ever-changing PAs. They were sometimes unknowledgeable about pain meds. I knew more about opiates than some of the PAs. Because the doctor was trying to make as much money as possible, herding patients in and out, I just mainly saw these inexperienced PA's that were a revolving group of people that would quit or get fired.
The guy just seemed like he wanted to rake in the most money possible.
So they triple booked.
That meant the usual wait to see anyone was around a 45 minute wait. That was annoying enough.
His front office staff girls were inept, and constantly screwing up my appointments. I would make an appointment for a specific date and time. i would show up at that time, and the front office girls would deny I had an appointment!
Yet, I would show them the appointment card that THEY filled out with that time and that date!
This happened on a handful of dates.
Then after a few years, I developed severe neuropathy. One of my other longtime doctors, who is my primary care doctor, mailed the pain doctor a letter, stating I now have neuropathy, and could he please treat me for it.
I then called the pain doctor's office, mentioning the letter that my other doctor said he sent to their doctor, and I then begged to see the pain doctor (not a PA) for help me with this painful neuropathy.
I showed up on the designated time and day of the appointment to see the pain doctor about it. But when I got there, they sent me to see a PA instead. I told the PA that I was there to see the real doctor, I wanted to see him about my neuropathy, I had made an appointment to see him, and I told the PA about the letter to him from my primary care doctor.
The PA left the room, and I could immediately hear the pain doctor in the hallway, going off that I did not have an appointment to see him, and why in the HELL was I there at his office?
I went out in the hallway, and I explained to the doctor that my primary care doctor had sent him a letter about my neuropathy, and that I had made an appointment to see him, and that this was the appointment's time and date.
As it turned out, the inept front staff never bothered to tell the doctor about the letter, or give it to him.
Nor did they bother to tell him I had an appointment scheduled with him.
No one there could even find the letter my primary care doctor had written to him about my neuropathy.
Frustrated, in front of the pain doctor, I grabbed my file, and I sifted through it, and I found the letter---just arbitrarily stuck in the middle of the over 4 years worth of paperwork in my file!
The pain doctor then gave me a shot for my neuropathy that was worthless, and he said for me to make an appointment to get another shot from him in 2 weeks.
He said his PA's don't give the shots. It has to be HE who gives it.
It was just some lidocaine type shot, and not an opiate, or any major drug.
So I did as the pain doctor told me to do, and I kept calling his office, begging for a follow-up appointment. The weeks and months went by, and I couldn't get an appointment with the doctor.
I was suffering, in so much pain from the neuropathy.
"He's booked up, he's booked up."
Meanwhile, I was really suffering from the pain of it.
Not only did I need to be treated for the neuropathy, but I also needed to be diagnosed for the neuropathy---meaning, I needed to find out the cause of it, why do I have it at such a young age, etc.
So after suffering for weeks of neuropathic pain, unable to get to see the pain doctor to get the follow up shot or talk to him, I finally made a consult appointment with another pain doctor/neurologist.
Then I called the old pain doctor's brand new office manager named Danny that I was going to see another doctor, just to deal with my neuropathy problem.
The office manager Danny said that if I did, I would be "violating the contract" and that I would be "doctor shopping."
I told him the whole story, that I had been trying to see the doctor for 4 months, and I had a right to treatment for my neuropathy, it had been going on long enough, I was physically suffering from it, and I had a right to a second opinion.
And I had a right to be treated.
This Danny guy then kept calling me on the phone, harassing me, saying that he talked to the doctor, and that the doctor said that if I see another doctor, he is going to put it in my medical records I am "shopping for drugs."
So not only was I being threatened for seeking a second opinion, and trying to get help for my painful neuropathy, but I was being LIABELED medically, in revenge, falsely accused of being a doctor shopper!
I said, "Look, I have a right to a second opinion."
The office manager kept threatening that he told the doctor I was doctor shopping.
I called the office repeatedly.
No one would allow me to speak to the doctor.
So when I came to my next pain appointment, they had a brand new PA for me to see (the previous one had now quit, too), so yet again I would not be seeing the doctor. So I would STILL not get help for my neuropathy.
Meanwhile, the Danny guy kept threatening me, of these dire consequences if I get a second opinion from another doctor.
Plus, he said they would cold turkey me from 4 years of opiates!!!!!
It gets worse.
The new PA, who didn't even know me, said he talked to the Danny office manager, and that he would now no longer give me my regular opiate pain pills. I asked him why he was switching my pain drug after 4 years, and he said, "These have less street value if you sell them," as if I was a dope dealer.
I was SO enraged by this, I never went back.
Pain doctors that use the tactic of labeling you as "doctor shopping," a drug dealer, and who threaten you as a patient, and that threaten to dangerously cold turkey you off your opiates if you want a second medical opinion (especially when they are not even treating you for a new condition, and they just pass you on to PA's that are inexperienced in pain management) should be investigated.
This doctor was just running a drug mill.
I took only ONE of the new pills the new clueless PA put me on, and I literally immediately blacked out for 24 hours!
I missed a day of work!
I was out cold for 24 hours! He overdosed me on that pill. And the idiot PA put on the pill bottle instructions that I was supposed to take TWO of these pills a DAY!!!!
I knew would have likely been dead if I followed his inept instructions.
I never took another one of those pills, and I never went back again.
But I am sure it is in my records, all this false accusation of doctor shopping, as revenge for going to another doctor.
I have not requested my records from that doctor, because I am afraid I would be too upset seeing the lies in them.
One day if I ever have time, I am going to report this place to the medical board.
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Old 06-08-2012, 05:33 AM
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Im going through this too, after almost 9 years with the same pill pusher it's time to move on. He's an internist and I need a pain manager. I've found a pain management doctor on the NJ DHSS registry and I keep telling my lawyer to make the insurance co. send me there. I have to find a doctor soon before I run out of pills. My old one wont see me anymore (long story). I take alot of Roxicodone (90mg every 3 hours) Exalgo & Lyrica and I have enough to hold me for a while but they better hurry up! Nobody does anything quick unless there's $$$ involved. I'll call the lawyers again tomorrow. What a pain in the back, leg, hip, and ass.
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Old 06-08-2012, 04:39 PM
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I feel your pain. I once a few years ago was fired by my pain management doctor. He never liked my spine surgeon and told me at the first appointment that he works closely with spine surgeons . When he asked who mine was he said "I don't work with him" so rocky start, things got OK and then one day when i had discography with another doc, he fired me , told me he couldn't treat me anymore.
Fortunately my spine surgeon found me a new pain management doctor right away.
But i did have a few weeks of panic wondering if i would have to endure pain without medication for a while.

Good luck to you in finding a new doctor
judy
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2007 ACDF 4-7
2008 hip , knee scope, hip replacement
2009 thoracic T-5 thru T-11fusion
2009 VATS T7-8, posterior only T11-12. removal of thoracic hard wear
2010 lung surgery
2010 T2-L2 kyphosis correction
2010 Kyphoplasty T-3, T-4
2011 Cervical osteotomy ,revision C4-T5
2011 Foot surgery
2011 Revision fusion T7 thru L4/laminectomy
2012 Hammertoe correction left foot
2012 Revision fusion T-12 thru L5
2012 Revision fusion L4-L5
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Old 06-08-2012, 07:02 PM
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Wow! I think that most of us who are chronic pain patients for a substantial length of time could write a book. I alreay have a title and I've asked my pain management doctor about making a presentation to his staff. It's called, "the indignities of being a chronic pain patient".

Having said that... Lisa, your story is really bad. There is no excuse for this type of treatment. I would consider writing the doctor a letter that expresses your concerns BRIEFLY. But, the letter would contain the threats and the fact that they changed your medications WITHOUT YOU HAVING A DISCUSSION WITH YOUR DOCTOR, and for no medical reason; seemingly in retaliation for the offence of insisting on seeing the doctor and for talking about seeking a second opinion.

If you have a change in symptoms and there is no doctor to consider the new symptoms and diagnose them appropriately, that is dangerous. It's possible that the new symptoms could be related to a problem separate from your source of chronic pain. (eg. diabetic neuropathy?)

Good luck... please keep us posted. If you don't get any appropriate response, I would switch to a new doctor AND file a complaint with the state medical board.

All the best,

Mark

PS... Eddie, IMHO we should be with a pain management doc when we get into the mode of maintenance meds instead of investigating procedure options. The only problem is that they are skewed to meds and procedure and don't have enough 'balance'. We are all in such a tough spot.
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Old 06-08-2012, 07:06 PM
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I was fired by my pain management doc after about 8 months with him.

"You are too mobile to be having the kind or pain you are reporting", he said.

About a month later, I leaned my head forward to rinse my hair in the shower and my left leg went numb. Thanks Doc. I liked getting some vindication, but that is worth little after the humiliation of being fired by the doc and the indignities I ran into when shopping for another. I can't write more now, but there is another worthwhile story there.

Mark
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2000 L4-5 Microdiscectomy/laminotomy
2001 L5-S1 Micro-d/lami
2002 L4-S1 Charite' ADR - SUCCESS!
2009 C3-C4, C5-C6-C7, T1-T2 ProDisc-C Nova
Summer 2009, more bad thoracic discs!
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Old 06-09-2012, 07:43 AM
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Default my pm

I adore him.. 8 years still seeing same person in San Diego. He likes that I'm as functional as I am and still writes my pain med script. I asked him point blank last visit if it was OK that I don't see him but every 5 or 6 months actually as the scripts written for every 3 months last me that long and he said "no of course not."

More to say tho back is killing me sitting since I've not been able to bear wt. on right foot this past week and am not cleared to do so until next Friday.

argghhhhhh.... back pain stinks
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Old 06-14-2012, 08:18 PM
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Default good grief

Okay: Acute is sudden on-set like from an injury or surgery..
Chronic; which is what most of us here are; it's everyday, continual, constant, and must be managed. Most doctors will only treat acute pain now or they will refer you to a "pain management doctor". The reason is simply that pmd most follow certain guidelines, screening, and testing of their patients. You must have urine tested every 3 months to make certain that you are actually taking the meds and not selling them. They look for certain levels based on you dosage so they can tell if you are taking it daily as Rx.
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Old 06-26-2012, 01:00 AM
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Quote:
Originally Posted by mmglobal View Post
"You are too mobile to be having the kind or pain you are reporting", he said.


This is the crux of pain treatment, and why it is treated so poorly.

It is self-reported, and a treating doc has zero insight into the level of pain. Zero, nada, nothing.

The med profession gives lip service to this, but at the end of the day they are in it for the power and ego gratification the position provides. There is nothing gratifying to the ego about having a patient tell you what level his pain is at.

It is far more gratifying to use your 'experience' and any other bollocks you care to come up with to interpret the patients pain.

If your interpretation is patently false, well, tough titties to the patient.

This is actually demonstrable incompetence, but a medical relationship is a power relationship, and the role of a patient is to be compliant and have no power over their own treatment.


So the problem is obviously the relationship, and the lack of power the patient has over their own treatment.

The solution involves empowering the patient, by actually giving them control over what goes into their bodies.

This would never happen, not because of the potential for proliferation of addiction, but because it is anathema to the medical profession that the patient knows their body and condition better than the doctor, and has a far deeper insight into what works and what doesn't.


You could argue with me on the last point, but I have dealt with enough dickheads in white coats to know that many of these twangers are in love with power and status more than they are with serving the needs of someone in strife as best they can.

Pain Management is one of the aspects of the profession where this relationship becomes amplified because

a) it is palliative
b) it lacks the status of the other disciplines, and probably attracts more also rans
c) the patients are mostly desperate and in terrible pain
d) there is no objective indication of successful treatment (similar to the mental health disciplines).


The answer to this problem lies something along the line of a fundamental shake up of the doctor/patient relationship, and the establishment of something similar to a patient bill of rights.

Something has to be done alter the balance of power in this relationship, as it is far too skewed.

The role of the doctor should be to advise the patient on the available medications and their long term effects and addictiveness. The choice should then be the patients to try certain medications.

If people want to abuse the system to obtain narcotics for recreational drug use, I am of the opinion that they should be allowed to. I would rather have a few more addicts rorting drugs out of the system than have people in genuine need be put aside. There is no way to tell the difference between the two. No way at all. Addiction is a choice you make when you ingest a drug: untreated pain is not a choice.

*****

It is unfortunate that such changes will not be made or even attempted, due simply to the arrogance and conceit of the medical profession.
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Old 06-26-2012, 01:29 AM
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I know that seems like a crazy rant but jeeze at some point a doctor has to be judged on their performance.

If you call a plumber to your house for a broken dunny and he turns a spanner a few times, gives it a kick, flushes it, watches it overflow all over the floor, then turns to you and says 'job done mate', you'd boot him up the arse and turf him out the front door and never hire the incompetent fool again.

But if you go to a doc and say ' I am in severe pain ', and he goes, 'nah you're alright', well everythings ok because it's the doc who decides what pain you are in not yourself!! patently ridiculous!!

And in everyones viewpoint it's the doc who is right, in society at large, the doc is a protected species.

As for the poor bugger who is disabled by pain, can't work, going down the toilet financially and may or may not have a family to help him out... well tough titties mate.

Most people in severe chronic pain are impoverished or rely on a family member to earn an income. Just a ridiculous situation, and totally avoidable.
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Old 07-03-2012, 10:17 PM
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Does acute pain mean in a small area? And chronic means a long time? I'm trying to learn my medical terms with you guys
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Old 07-03-2012, 11:43 PM
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Default re acute vs. chronic

Acute is rapid/sudden onset pain. Generally when discussing acute onset pain it means that it happened quickly. Not slow in development.

If pain is short lived and will recur esp. multiple times it's called "episodic"

If pain is ongoing for a period of time I think being 6 months to a year more or less every day then it's considered chronic in nature.

Another word used in pain management is intractable pain .. pain which can't be controlled or is very difficult to control.

Generally if one has a sprain, fracture, or broken bone they will have acute pain which will heal hopefully and not become chronic.

People who have a multiple back surgeries sometimes end up in chronic pain secondary to various reasons... whereas their intial back problem may have started with an acute onset of back pain and for a period of time a person may have had episodes of painful flareups and then may at some point progress to chronic pain (pain that is there all the time)...

Is this helpful? Hope so.
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Old 10-18-2012, 05:44 PM
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Went to workers comp court hoping the could find me a pain manager. Me & my attorney were yelling at each other because I told him he would be defending me harder aginst a detox had we had more face time together. He was offended by that as much as I was offended he went along with the 10 detox. I detoxed 2x this month and told the judge that. She said its the worst thing I can do and also said LYRICA is a widely abused drug too and I need to come off of that also. The ONLY doctor who has seen me in thae past 5 months (my primary care) wrote me a letter for court advocating pain management for me.
The judge said Liberty Mutual can pick whoever they want for me and they want me at a "clean slate". Easy for them to say. If you treat patients like a piece of meat maybe they;ll act like it eventually?

So Im preparing for detox AGAIN and the 9/10 pain that accompanies it. Im going to have to warn them that I tend to bang my head against the floor when I dont sleep for days and have horrible pain that make me want to die... FUN FUN 6-10 days for me but eventually I may get my surgeon.....after I get my pain manager.....after I get detoxed from deadly Lyrica (and Roxicodone which I will be detoxed from by the time I get to detox)
Whats worse is how money rules the system. I was told by this detox that they dont take people who are already detoxed. They take people in "crisis mode" but since my insurance prepaid they'll make a bed for me and the poor junkies or tweakers who may die without detox cant get a bed....Typical.....
__________________
12/16/03 Work Accident
Herniation and DDD at L4-L5
4/1/05 Discectomy
Epidurals and facet injections
5/15/06 Discogram confirmed L4-L5 DDD also an asymptomatic L5-S1 tear
10/24/06 L4-L5 Prodisc surgery with Dr. Goldstein
CAT scans & X-Rays show ossification
Trigger Point Injections, Medial Branch Blocks, Acupuncture, Weekly Deep Tissue Massage
10/27/08 Discogram (positive L5-S1)
11/25/08 L5-S1 fusion with Dr. Goldstein
FAILED BACK SYNDROME
Liberty Mutual WC
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  #19 (permalink)  
Old 10-20-2012, 05:22 PM
Eddie G's Avatar
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Join Date: Sep 2006
Location: Bayonne, NJ
Posts: 128
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Detoxing today to be detoxed for detox on Monday LOL!

I hope after these 10 day this pmd that they send me to will refer me to Dr. Goldstein. He's my only hope of getting out of this pain. I want them to fuse my Prodisc. They say its already autofused but I want pins & screws dammit! Autofusion isnt perfect! I need to get Goldstein to write me a letter saying he can help me! I think this new pmd will want to try antidepressants which I HATE! and the TENS implant! (Im not that lazy I cant remove TENS pads)
I cant believe Im going into a Detox even though Ive only been taking 15mg. Roxi ... THATS an ADDICT? My script was for 90mg. Roxi. Thats a healthy dose but I can get by on alot less BUT NOT NONE! Im afraid I may end up in a straight jacket fro the pain. It makes me literally bang my head on the floor when off my meds....

scary....
__________________
12/16/03 Work Accident
Herniation and DDD at L4-L5
4/1/05 Discectomy
Epidurals and facet injections
5/15/06 Discogram confirmed L4-L5 DDD also an asymptomatic L5-S1 tear
10/24/06 L4-L5 Prodisc surgery with Dr. Goldstein
CAT scans & X-Rays show ossification
Trigger Point Injections, Medial Branch Blocks, Acupuncture, Weekly Deep Tissue Massage
10/27/08 Discogram (positive L5-S1)
11/25/08 L5-S1 fusion with Dr. Goldstein
FAILED BACK SYNDROME
Liberty Mutual WC
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  #20 (permalink)  
Old 10-20-2012, 05:43 PM
Senior Member
 
Join Date: Jun 2010
Location: Sierra Madre, California
Posts: 904
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Eddie i wish you no head banging. I can totally relate to what you are going through. Although i did not have to come totally off meds, i developed a sciatic pain so severe that i couldn't walk and my old pm did nothing for me. So almost 6 weeks of the head banging pain.
Good luck with it all and i hope you get the referral soon to DrGoldstein.
judy
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2007 ACDF 4-7
2008 hip , knee scope, hip replacement
2009 thoracic T-5 thru T-11fusion
2009 VATS T7-8, posterior only T11-12. removal of thoracic hard wear
2010 lung surgery
2010 T2-L2 kyphosis correction
2010 Kyphoplasty T-3, T-4
2011 Cervical osteotomy ,revision C4-T5
2011 Foot surgery
2011 Revision fusion T7 thru L4/laminectomy
2012 Hammertoe correction left foot
2012 Revision fusion T-12 thru L5
2012 Revision fusion L4-L5
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