The story below is a preview from our July/August 2018 issue. For more, Subscribe today or view our FREE digital edition.
Pain management is more than simply treating a symptom, and includes battling addiction problems, pill mills and improving quality of life for those with lifelong conditions.
As a specialty, pain management has evolved from a hospital-based function performed mostly by anesthesiologists to predominantly outpatient treatment with providers having a variety of training backgrounds. This was partially driven by the rise of the palliative care model, for patients with a limited life expectancy.
After a conversation with your primary care provider, a referral to the appropriate pain medicine specialist is expected to increase the success rate and reduce the sub-specialty runaround. Physical medicine and rehabilitation (PM&R) physicians, also known as physiatrists, are experts in musculoskeletal conditions, much like an orthopaedist, but they do not do surgery.
These physicians, as well as neurologists, may be trained in providing pain management interventions such as physical therapy, medications, orthoses, nerve blocks and implants. Mental health providers may also be part of a pain management team, both for helping patients cope with chronic pain and also to help with drug addiction issues.
Dr. Monty Baylor, a partner at Blue Ridge Pain Management, associate professor at Edward Via College of Osteopathic Medicine and an attending physician at HCA Lewis-Gale Hospital, reminds us that “each patient is different and a holistic approach is needed.”
Baylor emphasizes that he is not just treating a symptom, but rather the whole person. When he does an assessment of needs, he looks for physical changes that can be made by medical interventions such as nerve blocks, but also the overall function of the patient in their current lifestyle. While some patients might never be pain-free, he can help improve quality of life and restore function in many cases.
Baylor suggests that his treatment paradigm is like a buffet table. While he has a vast array of options for patients, including medications, physical therapy, cognitive behavioral therapy, nutritional counseling and surgical intervention, not every patient needs to eat from the entire buffet. To identify the patient’s problem and how pain is being generated, he has a comprehensive program of testing, risk stratification and compliance monitoring that includes pill counts, urine tests and psychological screening. If a patient does not honor his or her agreement with him, he does not attempt to “make them feel subhuman,” as he put it. For example, if they use an illicit drug and it shows up on a urine screen, they may no longer be prescribed controlled drugs, but may still be offered other methods of treatment.
Baylor advocates that patients and referring physicians learn about the background of their pain management specialist. He is wary of physicians who claim they are pain management physicians, as the law allows many diverse backgrounds to legally advertise and practice under the specialty.
The downside, especially in rural areas, is that many of these non-board-certified providers end up running so-called “pill mills.” Some of these practices offer plans of a monthly fee paid in cash, and no insurance is billed. Opioids may be the only treatment offered, without such adjuncts as physical therapy and counseling. Baylor has seen patients in his office that have been prescribed up to 200 opioid pills a day from multiple clinics. Baylor believes that “illicit pharmaceuticals are diverted from manufacturing facilities in other countries and dumped on the street.” He also noted that not all ‘pain clinics’ test patients for illicit drugs.
“Among people who die from overdoses, 80 percent were taking opioids not prescribed to them,” says Baylor. He believes the majority of deaths are from illegal drugs or legal substances used inappropriately.
Baylor welcomes regulation and oversight, much like that done for hospitals by The Joint Commission, were there any such governing body for outpatient pain clinics. He would also welcome a requirement for board certification for all those practicing within the specialty. He wishes outpatient offices were managed to at least the minimum standards that a restaurant goes through.
Baylor says, “In restaurants, the health department is required to visit at least annually, to check for general safety and cleanliness, and to ensure that food is safe and stored at the proper temperature … Some of my medications also need to be stored in temperature-controlled environments and nobody is coming around to check.”
In January 2018, Nancy Agee, CEO at Carilion Clinic, created a multidisciplinary task force for the opioid crisis. The investment made is significant and includes an interdisciplinary staff headed up by psychiatrist Dr. Robert Trestman, along with Dr. Shaheen Lakhan.
Lakhan is a board-certified neurologist and pain medicine specialist. He moved to Carilion Roanoke Memorial Hospital in September, 2017, from Massachusetts General Hospital and Harvard Medical School. He chose Roanoke because it is a “hot spot” on the map nationally for opioid issues, yet a great place to raise a family. Now Chief of Pain Management for Carilion Clinic, he describes our opioid crisis as an “epidemic of chronic pain.”
Lakhan’s vision and mission at Carilion Clinic, in partnership with Virginia Tech Carilion School of Medicine, brings together clinicians, learners, scientists and the community in an integrated and comprehensive pain management service. The service focuses on functional restoration training within the seven dimensions of wellness (physical, emotional, intellectual, occupational, social, spiritual and environmental). In his role as co-chair for the system-wide opioid committee, he will work to mitigate the risk of opioid dependence among Carilion patients. He has already begun engaging with national policy makers on behalf of Carilion Clinic, including drafting a letter to the Senate Committee on Finance, chaired by Senator Orrin Hatch, on “measures that may mitigate the development of opioid use disorder (OUD).”
The many sub-specialities within medicine can be confusing. Having a strong relationship with a primary care practitioner enables patients to make better informed decisions. As care becomes more complicated, a primary care provider (PCP) will have relationships with trusted subspecialists throughout the community and will consult them as needed. The PCP is the quarterback of your health care team and should be relied upon for appropriate referrals.
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