Q and A on Multidisciplinary Pain Management: Pain Clinic, Medications

Chronic pain is the result of an injury or malfunction of peripheral pain receptors or central nervous system. Chronic pain not responding to conservative treatment such as medications and manual therapy are treated with interventional pain therapy and surgery. Chronic pain patient is referred to Multidisciplinary Pain Clinic, when patient does not respond to opioids, adjuvant pain medications, manual therapy, interventional pain therapy and surgery

Pain clinic is a medical clinic where patients suffering with chronic pain are treated. Several different medical specialties offer treatment of chronic pain through their pain clinic. Chiropractor may provide pain management through chiropractic pain clinic providing chiropractic treatment. Similarly physical therapist provides pain treatment using physical therapy and interventional pain specialist also provides pain treatment through their clinic some time called as “Block Clinic”. Service provider either physician or chiropractor at pain clinic specialized in one specialty may not prescribe pain medications.

Chiropractic clinic, Physical Therapy Clinic and Interventional (Injection or Nerve Block) Clinic are specialty clinic.

Yes, most physicians practicing specialized pain management write pain medications. Anesthesiologist managing interventional pain clinic in private practice prefer to write pain medication so physician can monitor patient’s prescriptions. While, anesthesiologist practicing pain medicine in academic center prefer to write pain medications as long as patient needs interventional (injections, nerve block etc.) treatment. Physical Medicine Rehab (PMR) physicians may or may not prefer to write opioids. Non-opioid medications are prescribed along with physical therapy as long as physical therapy treatment is necessary. Similarly chiropractor will continue writing selective pain medications as long as chiropractic treatment is prescribed.

Chronic pain is intense and continuous, often restricts indoor and outdoor activities. Patient is referred to Multidisciplinary Pain Clinic, when all the options of treatments like medications; manual treatment, interventional pain therapy and surgical treatment have failed.

Primary care physician or specialist refers patient to multidisciplinary pain clinic. After completion of treatment at “Specialty Clinic” patient is discharged for continuation of treatment to primary care physician. Primary care physicians may refer patient back to specialist or Multidisciplinary Pain Clinic depending on demand for pain medications and pain relief. Specialist mostly surgeon may refer patient to Multidisciplinary Pain Clinic.

In the past “Multidisciplinary Pain Clinic” was responsible to evaluate patient’s chronic pain by involving physicians of different specialty like PMR physician, Anesthesiologist, Psychologist or Psychiatrist and Surgeons. Specialist would see patient in same office and discuss treatment options every 2 to 4 months during schedule meeting attended by all specialist. Goal of multidisciplinary approach was to eliminate unnecessary and duplication of investigations and treatments. Most of the Health Insurance Companies and Third Party Payers refused to pay for treatment since multiple consultations were involved each time patient came to clinic for same problem like pain.

At present patients are seen by 2 or 3 specialist at multidisciplinary pain clinic (MPC). Specialist who participates in such MPC pain management are anesthesiologist, PMR physician and Psychologist. If necessary patient is referred to specialist like surgeon for second opinion. Interventional pain specialist monitors and conducts most of the pain management of the patient at MPC. Interventional pain specialist is trained through one year Fellowship in Pain management at accredited training program. Interventional pain specialist is also eligible for board examinations. There are two board examinations for interventional pain specialist. Pain board examination held by American Board of Anesthesiology, which is accredited by ACGME and need one year fellowship training to be eligible to sit for examination. American Board of Pain Medicine holds alternative board examination. Physicians who are not eligible for fellowship training or prefer not to go through fellowship training are eligible for Pain Board examination held by American Board of pain Medicine after 2 years of experience in pain management practice. Physicians who are board certified by American Board of Pain Medicine are not fellowship trained and board examination is not recognized by ACGME.

Yes, the patient is seen for follow up by interventional pain specialist (IPM) at schedule interval and will refer patient to PMR physician or psychologist either at schedule interval or when necessary. Interventional pain specialist may refer patient to specialist like surgeon for second opinion or when necessary for surgical treatment. Goal of MPC is to control pain and prevent unfavorable and harmful treatment.

Yes, patient will see interventional pain specialist, PMR physician and psychologist at same office. Few practices may provide services of interventional pain specialist and psychologist at same office, while PMR physician may be available at different office. If referred to surgeon then patient will be seen at different office.

All physicians practicing in same office will share record. If patient is referred to specialist then part of the record will be sent after approval by patient. Records are safe and guided by HIPPA guidance.

Patient suffering with chronic intractable pain and not responding to medication, physician therapy, interventional therapy and surgery are treated at Multidisciplinary Pain Clinic. Majority of patient participating in pain management with multidisciplinary approach suffer from –

• Cancer pain
• Non-cancer pain:
  1. Low back pain
  2. Fibromyalgia
  3. Headache
  4. Pancreatitis
  5. Neck Pain
  6. Complex Regional Pain Syndrome
  7. Post Herpetic Neuralgic or Shingles Pain
  8. Trigeminal Neuralgia or Facial Nerve Pain.