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  "text": "Hey, [PERSON_NAME]. Good to see you again. How have you been? Tell me how it's been going. Oh, the pain is just still a real problem. Man, I'm sorry to hear that. Still having lots of pain? Yeah, it's just with me all the time. Tell me a little bit more about that. Well, when I get up, it's like somebody's been beaten on my back with a hammer. Takes me [DURATION] [DURATION] just to get out of bed. It's gets a little better once I start walking, but the [DRUG] I'm taking are just not doing what they used to do. So it seems to be getting worse instead of better? Yes. Wow. Well, you remember we used this pain scale before. Tell me where your pain the average pain level over the past week for you. If 0 is no pain at all and 10 is the worst pain you've ever had? Well, I'd have to say it's around 8. Wow. How about you take the [DRUG]? Well, I'd have to say it's really nine and then eight with the [DRUG]. So it doesn't get much better than that. It's with me all the time and it's interfering with everything I do. Severe pain all the time. What about your general enjoyment of life? To what level? On that 0 to 10 scale, is the pain interfering with your general enjoyment of life? Well, it's hard to enjoy life when you're in pain all the time. I'd have to put that up there at around 8 too. So life's not much fun. No. Wow, I'm sorry to hear that. What about your activity level? You remember one of the things we want to do with this [DRUG] is try to get you more active doing the things you want to do. On a scale of 0 to 10, how much is the pain interfering with your general activity level? It's interfering a great deal. I'd say about, I guess maybe seven or eight because it just hurts to do anything. So you're still not able to do the things that you really want to do? No, I can't work. I mean, even doing anything hurts and even sitting down hurts. If I move suddenly, then I get a sharp pain and it's just with me all the time. It just seems like the [DRUG] not working. I think I need something stronger. Well, we started at the [DRUG] [MEDICAL_PROCESS] [MEDICAL_PROCESS] [MEDICAL_PROCESS] [MEDICAL_PROCESS] [MEDICAL_PROCESS], and then we went up to [MEDICAL_PROCESS] [MEDICAL_PROCESS] [MEDICAL_PROCESS] [MEDICAL_PROCESS]. Tell me how you're taking your [DRUG]. Well, I try to take it pretty much like it says to take it. And I've noticed that I have Taken it. I've doubled up on it a little to try to. It doesn't seem to be doing much good. Even when you double up. Right. Tell me what happened. Well, it's. It may increase the pain relief a little bit. It also makes me feel kind of drowsy and woozy, and it's just not. It's just not doing what it's supposed to do. Yeah. Yeah, I noticed that the last time you were here. It seemed like you were drowsy or sleepy, almost a little bit drugged. So you have that feeling? Sometimes. Sometimes. Tell me what else you've tried to decrease your pain? I know last time we talked about trying to increase your exercise, maybe walking more, and I wrote you a prescription for some [MEDICAL_PROCESS] [MEDICAL_PROCESS]. Have you done any [MEDICAL_PROCESS]? Well, I tried the walking. I checked out the [MEDICAL_PROCESS], but to me, it was like, you know, I can't do this stuff working out and things like that. I can't do that with the pain I'm in. And the walking doesn't seem to help much either. Mm. Sometimes a little bit of movement will help. I can stretch, but as far as any significant walk, it is just too painful. Yeah. So activity of any kind seems to make things worse. Yeah. Well, I had something I needed to ask you about, [PERSON_NAME]. I got a letter from your insurance company, and they. They said that you've been getting [DRUG] from two other [OCCUPATION] besides me, which is something we agreed on your original visit that you wouldn't do. What can you tell me about that'll be a mistake. Somebody just made a clerical error or something, because that. That didn't happen. Well, I checked the prescription monitoring program as well, and they also show that [PERSON_NAME] [PERSON_NAME], with a birth date of [DATE_OF_BIRTH], [DATE_OF_BIRTH], has gotten [DRUG] from. Well, somebody just got my information. Then that's got to be what happened, because that's. I didn't do that. You didn't go to any other [OCCUPATION]? Somebody just got my information from someplace. Well, I'm concerned, and I hear that you're dealing with a lot of pain. I'm concerned that the numbers that we've had when we started about your pain and your activity, we haven't really budged those at all. And then some other things. You called in the middle of the [DURATION] this time that your prescription had been stolen. We really don't like to refill after that. We got extra [DRUG] this [DURATION]. I just think I need something stronger. This stuff's just not working like it used to. So you're feeling as maybe More [DRUG]? Yeah. Yeah, I think so. Well, I guess I have to say I feel like maybe the opposite is true, that maybe we're doing more harm than good with the [DRUG]. When we first talked, we talked about the fact that these are dangerous medicines. So sometimes you get more pain, you take more [DRUG], and then suddenly you go to sleep and you don't wake up. And I really don't want that to happen with you. Well, then there's some other kind of [DRUG] that's not quite like that, something that'll work. I mean, I'm kind of at the end of my rope here. Yeah. Well, there are some other options, and I want to talk through them with you today. I guess one of my first concerns is whether the [DRUG] have become a part of the problem. Sometimes people, you know, they get pain, they take a [DRUG], they take another [DRUG], and then suddenly that takes on a life of its own, and their life begins to revolve around the [DRUG], and it gets chaotic and they're getting side effects and scale. Scary things happen, and they wonder if maybe the [DRUG] have become the main problem. I'm wondering, you know, have you ever thought about that? Do we need to be talking about [MEDICAL_PROCESS] today? [MEDICAL_PROCESS]? No, I don't think so. I don't think so. I think I just need something stronger. You don't think the [DRUG] have become a problem for you? That they're just creating more and more craving for more and more [DRUG]? Not really. All I know is I just. I have to have them. But now they're not working, so I gotta have something. Yeah. Well, let me talk to you about another option. You remember we talked in the first visit about sometimes the [DRUG] [DRUG] actually increase the pain level. We don't really understand why that happens, but the pain actually gets worse, and that creates a cycle because you take the [DRUG] and the pain's worse. So you want to take another [DRUG] or then we increase the pain. Maybe that's what's happening to me, because it just seems like it's not working. And it could be that it's getting even worse. Yeah, it just seems like it's not working at all. That's why I think I need something stronger. Yeah. Well, if the [DRUG] is actually the problem, then the answer for that is actually to [MEDICAL_PROCESS] you off, to taper them down, come completely off the medication and see if the pain gets better. Now, I think with your [MEDICAL_CONDITION] [MEDICAL_CONDITION] [MEDICAL_CONDITION] that you have, it's unlikely that the pain will go completely away, but it may come down to a 6 or a 5 or a 4 if we get rid of the [DRUG]. So what we do in that case is we taper you off the medicines over about a [DURATION] period of time. And what I like to do is engage people with a support group because it's a challenge coming off the [DRUG] after being on a long time, that's pretty scary. It didn't make any sense to me to come off the [DRUG]. I mean, how can coming off the [DRUG] make the pain better? Well, if the [DRUG] actually increased your pain and the pain does get better and we've seen it numerous times and so that would be an option. I can see how that could be happening because I took take it and then eventually it reaches a point where it seems like it's not only not working, but maybe even being worse. So why not just use something? There's something different I can take. Well, I just don't feel like the [DRUG] are safe for you. Now the one, the one other option that we have is medication called [DRUG] or [DRUG]. And, and it replaces the [DRUG] that you're on. It gives a moderate amount of pain relief, probably not as strong as the [DRUG], but it stops the craving and it sort of gets you out of that cycle of chasing medicines and looking for [DRUG] all the time and allows you to go on and focus on other ways to relieve your pain. We could get you into [MEDICAL_PROCESS] [MEDICAL_PROCESS], actually try that. Or if you'd rather, sometimes meditation helps people. So that would be the third option, is we can switch you over to the [DRUG], increase some of these [MEDICAL_PROCESS] [MEDICAL_PROCESS] [MEDICAL_PROCESS] [MEDICAL_PROCESS] [MEDICAL_PROCESS] and see if you don't get better. I can see some logic in doing that, but I just think that right now I just need a stronger something to get this pain away first before I look at anything else. If I can do that and get rid of the pain, then maybe I can, you know, talk about some of those other things after that. Yeah, well, [PERSON_NAME], I'm just at the point where I don't feel like the [DRUG] are safe for you anymore. So I'm not gonna write you any more [DRUG]. I'd be willing to go with tapering we talked about, or with the [DRUG] or send you to detail. I know what kind of pain I'm in and if you're not willing to give me what I need, then I'm going to have to go somewhere else and try to get it. Well, I'm sorry that you feel that way, but sometimes we just sort of have to agree to disagree. I think some of these other options might be safer for you. I'm happy to care for your other problems. We'll continue to treat your [MEDICAL_CONDITION] and your other medical needs, but I'm just not comfortable writing the [DRUG] anymore. So if you feel like you need to find someone else to do that, you go ahead. If you think about it, and these other options sound good to you, the door is open. You can call me at any time. Well, I think that's what I'm going to have to do. I appreciate what you say, and I'm not closing the door on it, but I know what I've got to do for myself right now. Okay.",
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