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Interventional Pain Management is the Practice of Medicine

Interventional pain management by unqualified providers presents serious risks to patients, such as persistent or worsened pain, bleeding, infection, nerve damage, brain damage, paralysis or even death. Therefore, it is the position of the American Society of Anesthesiologists that interventional pain management of patients suffering from chronic pain constitutes the practice of medicine. Appropriate medical training is necessary to evaluate, diagnose and safely treat patients suffering from chronic pain and to respond to complications of treatment should they arise. The public safety requires that interventional pain management in statute and regulation as clearly recognized as the practice of medicine and the interventional treatment of pain is provided only by qualified MDs/DOs.

Due to the complexities involved in the treatment of pain, pain medicine is recognized as a separate medical subspecialty by the American Board of Medical Specialties. Physicians choosing to specialize in pain medicine must now complete a one-year multidisciplinary pain fellowship in addition to successful completion of four years of medical school and four years of anesthesiology residency or appropriate residency training in physical medicine and rehabilitation, neurology or psychiatry. Medical school is a four-year program, where the first and second years are spent learning the scientific principles of human anatomy and physiology, biochemistry, pharmacology, genetics, microbiology, immunology, pathology of disease states, and similar courses in both the natural and behavioral sciences, as well as in introductory clinical experiences. The third and fourth years of medical school are devoted to full-time clinical rotations and clerkships where the medical student is introduced to the comprehensive clinical care of patients, primarily in the hospital inpatient setting. After successfully completing a residency program and a one-year pain medicine fellowship, they may apply to enter the examination process leading to board-certification in Pain Medicine. The requirement for multidisciplinary pain medicine fellowship training is recognized by the Accreditation Council for Graduate Medical Education who oversees and accredits the programs.

Careful selection of patients for interventional procedures is necessary in order to increase the chances for success and reduce the risk of harm. Patient selection requires a detailed evaluation of the complex pain patient, including but not limited to, a medical history, physical examination, diagnostic testing and imaging, and determination of the diagnosis prior to developing a multimodal medical treatment plan incorporating interventional pain management procedures. The advanced skill set of a physician with specialty education and training in pain medicine involved in this patient evaluation and development of a treatment plan are integral to the practice of medicine.

Many complex interventional pain procedures require the use of advanced imaging techniques (e.g. fluoroscopy, digital subtraction angiography, computerized tomography and others) to accurately guide needles to the proper location, evaluate potentially therapeutic or dangerous spread patterns for medications injected via the needles and assist in the intraoperative placement of devices. Proper knowledge of imaging safety considerations and technical interpretation of advanced imaging and management of potential life threatening complications require highly specialized medical training.

As an example, fluoroscopic imaging either alone or in combination with digital subtraction angiography is a vital imaging technique used to assist interventional pain physicians in the diagnosis and treatment of pain. A clear understanding of how to obtain and interpret fluoroscopic images is critical to obtaining successful outcomes and avoiding devastating complications. While this tool helps to safely and effectively perform interventional pain procedures, the risk of radiation overexposure to patients and staff increases when professionals who are partially or inappropriately trained engage in operating the fluoroscopy unit. Hence, in addition to formal pain medicine training, many states have established a rigid certification process for physicians to use this device.

Some state nursing boards have unilaterally and unlawfully moved to expand scope of practice by allowing non-physicians to perform interventional pain medicine procedures. For example, the Louisiana State Board of Medical Examiners adopted an advisory opinion that certain procedures—including the injection of local anesthetics, steroids and analgesics, peripheral nerve blocks, epidural injections and spinal facet joint injections, when used for interventional pain management of patients suffering from chronic pain—constitute the practice of medicine and may only be performed by a physician. In 2009, the Louisiana First Circuit Court of Appeal affirmed the trial court’s declaratory judgment that the Louisiana State Board of Nursing’s advisory opinion improperly expanded the scope of practice of a nurse anesthetist into an area where they have not traditionally practiced and that the practice of interventional pain management is not within the scope of practice of a nurse anesthetist, but rather is solely the practice of medicine.

Additionally, ASA endorses the policy of the American Medical Association, which is to encourage and support state medical boards and state medical societies in adopting advisory opinions and advancing legislation, respectively, that interventional pain management of patients suffering from chronic pain constitutes the practice of medicine.

For further information, please contact Ronald Szabat, ASA Executive Vice President & General Counsel, or Lisa Percy Albany, ASA State Legislative and Regulatory Issues Manager, at (202) 289-2222.

February 2009