I said no to a patient yesterday.
The patient came for a fifteen minute get to know you visit. I don't charge for this.
The patient came all the way from Whatcom County. I am in Jefferson County, Washington. That is about 99 miles but involves a ferry ride from Whidby Island to Port Townsend. So it must take at least three hours each way.
The person is on suboxone. Their provider is going to cash only January 1, 2017 and won't take insurance. I had no notes from the provider, only from the primary care doctor. I don't know if the suboxone is being given for opiate overuse, or for chronic pain. The person only admits to chronic pain and denies opiate overuse. The use for chronic pain is off label and I don't do that: it's too confusing and we are all afraid of the DEA and authorities.
I already have patients from Jefferson, Clallam, Island and Kitsap Counties.
I called the person's primary care doctor and I forwarded the information to the University of Washington Pain Clinic. They are swamped as well, after the Seattle Pain Clinics closed: http://www.seattletimes.com/seattle-news/health/the-whitecoats-dont-care-one-mans-desperation-and-death-when-pain-clinics-close/. They are giving priority to the people with implanted pain pumps, because the rest of us aren't trained in those dosage adjustments.
And I need to sit down and read the CDC guidelines for chronic pain. The short version: https://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf and the long version: https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm. It is a fifty page PDF. Try doing the two page one in a fifteen minute clinic visit. Ha, ha, good luck. And then make sure you can tell the difference between an opiate overuse person and someone who only has chronic pain: easy, peasy, right? I find that they ALL say they have chronic pain and no opiate overuse. ALL OF THEM. Well, except the heroin folks. The heroin folks are easier because they never say they don't have a problem. It's still emotionally difficult because about 1/3 quit treatment with me and then some die. In their 30s. In their 40s. In their 20s. I mind.
It's such a mess. If a person gets started on suboxone, yeah, it will work for chronic pain too, but what if I get hit by a truck? There aren't anywhere near enough prescribers, docs are quitting, and it's labor intensive. The doctor is going to cash payments in Whatcom most probably because they are just sick of the huge mass of paperwork and restrictions and worrying about medicare or medicaid coming after them.....
....but I have limits as well....only four counties.
I need some cheering up, dang it. Wine, wine, wine... nope. Ok, one person said last week that he feels better then he has in YEARS and brought me a Christmas card.....'taint all bad.