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March 1, 2013 Volume 77, Number 3
Stringent Educational Requirements Should Be a Hallmark of Physician-led Pain Care Rafael Miguel, M.D.


ASA has launched an aggressive effort to bring the importance of physician-led pain care to the attention of the public, legislators and the medical community. Communications initiatives have focused on drawing attention to policies which could allow untrained non-physicians to diagnose and treat medical conditions. A new communications effort at www.physician-paincare.com introduces the public to these crucial issues and the important role anesthesiologists play in the delivery of safe pain medicine.

Patients experiencing chronic pain face a number of challenges, most notably their ability to live in comfort without daily suffering. As physicians, we sometimes aim to simply relieve their pain without fully acknowledging the effects of their condition on their life and surroundings.

Beyond personal suffering, chronic pain is associated with an enormous impact on workplace productivity. The estimated annual cost of chronic pain on society is $100 billion, including not only health care expenses, but lost income and lost productivity. Common ailments include headache, back pain and arthritis, all of which can impede a person’s ability to perform daily tasks.

To combat lost wages and improve productivity, pain management is a common recourse to keep people on the go. Recognizing this, the Centers for Medicare & Medicaid Services (CMS) recently enacted a new policy allowing uneducated and untrained nurses to directly bill for pain management services. This puts patients in great danger of complications.

We’re now faced with a crucial question: What education and training should be absolutely necessary for effective chronic pain treatment?

To treat a patient in chronic pain successfully, completion of a medical school curriculum, a residency in a related discipline and even an ACGME Pain Medicine Fellowship, is absolutely essential. Necessary advanced knowledge in anatomy, physiology and pharmacology can only be obtained in medical school.

Additionally, there are often co-existing medical issues associated with chronic pain that can only be diagnosed and treated by licensed physicians. For instance, there are several psychiatric conditions such as depression and general anxiety disorder that can either cause chronic pain or can be triggered by chronic pain. Only physicians are provided the proper diagnostic and management skills needed to properly treat all facets of pain. Without training and skills nurtured during residency, it’s impossible to correctly screen for, recognize and select the best medications to be used in tandem with mental health therapies.

Nonphysicians often rely on opioids for pain relief. This poses a high risk of significant patient harm, will result in substandard results and, quite frankly, is destined to fail. Since a variety of medication classes are used when treating chronic pain patients, the potential for dangerous drug interaction is heightened. The ability to manage these adverse events, including sedation, confusion, constipation and more, again requires years of medical school and residency programs.

The greatest chance for successful treatment is an interdisciplinary approach, where various specialties collaborate to create a well-rounded care plan. Ideally, orthopedics, neurologists, rheumatologists, physical therapists and others work together to ensure all avenues of care are evaluated and executed properly.

Using interventional pain management (IPM) is another critical component in creating a safe environment for patients. Combining IPM techniques with medical management minimizes reliance on controlled substances for pain control. As noted before, these skills also need to be learned, expanded upon and refined during medical school and the years in residency.

As lower back pain is one of these most common chronic illnesses, pain management around the spine is common and, unfortunately, a very perilous area. Using ionizing radiation, such as fluoroscopy and CT scanning, to guide and identify the most accurate and safe location for needle placement and injection is vital. Only proper training provides the skills necessary to use radiation safely and to accurately interpret images.

There are a multitude of potentially disastrous outcomes of improper spinal exploration. Nerves can be damaged beyond repair, and even proven targeted drug delivery, such as pulse generator and intrathecal pump implantation, can cause great harm to patients when performed by an untrained practitioner.

Quite simply, the single greatest factor in helping patients enjoy a successful outcome and reduce the risk of chronic pain treatment is an extensive education and training program for practitioners. These lessons require years of dedicated and directed learning, which cannot be achieved by any other route than that obtained in medical school, residency and ideally, an ACGME-accredited Pain Medicine Fellowship program. Without these stringent standards, we do our patients a disservice by putting their care in untrained hands, making them vulnerable to complications even worse than chronic pain.



Rafael Miguel, M.D. is Medical Director, Pain Medicine Program, Sarasota Memorial Healthcare System; private practitioner, Brandon Pain Medicine, Brandon, Florida; Professor (adjunct), Pain Medicine Program, Department of Neurology, University of South Florida, Tampa and Sarasota.

Bibliography:
• Stewart WF, Ricci JA, Chee E, Morganstein D, Lipton R. Lost productive time and cost due to common pain conditions in the US workforce. JAMA. 2003 Nov 12;290(18):2443-54.
• National Institutes of Health, NIH guide: new directions in pain research: 1. Bethesda, MD: National Institutes of Health. 1998 Sept. 4
• Crow W, Willis D. Estimating Cost of Care for Patients with Acute Low Back Pain: A Retrospective Review of Patient Records. J Am Osteopath Assoc. 2009:109:229-233.