Do I Need a Pain Doctor?
The role of pain doctors explained by Denver, Golden, Aurora, Boulder, Broomfield, Jefferson, and Littleton Colorado’s top pain doctors
Pain doctors or pain specialists are medical doctors who have received additional specialized training, after completing the general training in medical school, in the diagnosis and treatment of pain. Given the rapidly expanding technology in researching and treating the human condition, these specialized physicians are able to keep up-to-date with the most innovative techniques and treatments available for helping patients achieve relief from their symptoms of pain and discomfort.
“The aim of the wise is not to secure pleasure, but to avoid pain.” ― Aristotle
Pain, in most instances, is biologically necessary. The experience of pain is the body’s way of alerting us that there is something wrong. The processes underlying the experience of pain are very complex and are both chemical and neurological in nature. In fact, there are still aspects of the sensation of pain that are not well understood. Indeed, pain is as much a sensory experience as it is an emotional one. Pain and discomfort can be stressful and very upsetting for the individual, particularly in instances of chronic pain. The International Association for the Study of Pain defines the experience as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Moreover, the sensation of pain can vary widely from individual to individual, even in instances where the source for the pain is the same. In some instances, the underlying source for the pain may not even be identified.
Given the complex system of processes that underlies pain and the high degree of individual variability, it can be a difficult symptom to reliably measure. Typically, pain doctors will rely upon an individual’s own unique experiences of pain as a scale. Other ways in which pain can be described is the individual’s own report of intensity (i.e., “How bad is your pain?”), location (i.e., widespread versus localized to a specific area), duration (i.e., “Does it come and go, or is it persistent?”), and severity (i.e., dull and achy or sharp and piercing). Perhaps the most interesting aspect about pain is that it does not reliably reflect the level of tissue damage. A very small and shallow cut or abrasion may be capable of producing a high degree of excruciating pain, while more significant and severe injuries can be experienced as no worse than an average headache.
As mentioned early, pain serves the important biological function of alerting us of underlying damage or injury. However, the sensation of pain may persist even when the underlying problem has been treated or resolved on its own. In some instances, pain may emerge when no underlying tissue damage or other problem can be identified. This can be very distressing for the individual suffering, and may result in worsening symptoms that leads to a reduced quality of life and possible disability.
What is A Pain Doctor?
Sometimes referred to as Western medicine, the field of allopathic medicine is rapidly advancing as new developments in science and technology are made every day. This field of general practice encompasses the medical practice of using pharmacological or other physical interventions to address various diseases or conditions. Given how broad this field has become, training to become a physician has become more rigorous and extended than ever. In fact, the ever-expanding field of biotechnology has become so accelerated that no physician is able to stay current in terms of every health topic available. Because of this rapidly expanding knowledge base, many physicians have chosen to specialize in one or more related areas. This allows them to stay most current in their specialty field. Primary care physicians, then, are at somewhat of a disadvantage, given that they must keep up with all topics of health. Primary care physicians must also monitor the general health of all of their patients and will refer them to a specialist should their condition be beyond the scope of their practice.
Pain management, which can also be referred to as pain medicine, is one field of specialized training available to physicians once they complete generalist training. It is not surprising that the challenge in treating pain has been a topic of inquiry throughout all of written history. Despite this, pain management has only recently been recognized as a specialized field of training and research. Indeed, the field of pain management emerged as its own entity around the late 1980s and early 1990s. Prior to this time, anesthesiologists typically practiced pain management as subsidiary to their primary role and generally focused on helping the patient manage the symptoms of pain, rather than address any of the underlying factors involved in the cause of the pain. Currently, physicians who specialize in pain management are involved in both helping to relieve the symptoms of pain, as well as address the condition and related factors that underlies these symptoms. Pain doctors are highly trained in diagnosing the underlying causes for pain and in developing individualized treatment plans. Many pain doctors will work closely with the patient’s primary care physician, as they are able to more closely monitor the patient’s overall health and history, as well as provide ancillary information regarding the course of symptoms.
Without an in-depth understanding of the process of pain and the complex interactions that underlie this process, diagnosis, management, and treatment of pain would be aimless and unreliable. First, pain doctors must understand the differences between the various physiological types of pain. The most common of these include neuropathic, nociceptive, psychogenic, and incident. There are other types of physiological pain that are less common and generally associated with specific conditions.
Neuropathic pain is generally associated with irritation or damage to the tissue that comprises the nervous system. More specifically, nerve fibers that transmit sensory information can become irritated or damaged in a number of ways, such as from compression of nearby tissue as the result of inflammation. This then causes the affected nerve to send abnormal signals to the brain of pain and discomfort. In nociceptive pain, the pain and discomfort is specified to the activity of pain nerve fibers that transmits the signals of injurious, noxious, or thermal pain to the brain.
Psychogenic pain is pain that is caused or worsened as the result of factors related to behavior, cognitions, or emotional states. Indeed, the phrase “all in your head” is commonly used to describe this type of pain, though this is highly inaccurate as these factors are associated with many physical changes in the body that can be related to pain. Examples of psychogenic pain include headaches or stomachaches during times of increased stress and anxiety.
Conversely, incident pain is pain that is caused by activity or movement. For example, the pain and discomfort felt when attempting to move a joint that is sore and achy or when applying pressure to a bruise or wound is described as incident pain. Less common types of pain include that which results from cancer and its treatment and phantom limb pain experienced by amputees.
Pain doctors receive formal training in the most advanced techniques for assessing and diagnosing a broad range of pain symptoms and conditions. Moreover, pain doctors also are able to identify the other factors that may contribute to the patient’s pain condition, such as coping, social support, and secondary gains. This provides the pain doctor with a strong conceptual framework from which to develop an empirically based and individualized treatment plan.
What is An Interventional Pain Doctor?
Notwithstanding the youth of the field of pain management, there are a variety of modalities for the treatment of pain that pain doctors may specialize in—one of these being in interventional techniques. Thus, an interventional pain doctor has expertise in the treatment of pain using minimally invasive to invasive methods for managing various pain conditions. While the first interventional techniques for managing pain began by cutting the nerve fibers that transmitted pain signals to the brain, currently there are a number of interventional techniques available that utilize advanced and sophisticated technology to treat conditions of refractory pain. These techniques can vary widely in their degree of invasiveness and durability.
Prior to developing a treatment plan, an interventional pain doctor will ensure that they have fully and accurately assessed the patient’s current symptoms and relevant personal history. This information then informs their decision-making for an appropriate interventional technique to employ. The decision to utilize an interventional approach generally takes into account individual patient characteristics. Thus, the interventional pain doctor will consider the risks and benefits for each available intervention. Moreover, it is essential that the interventional pain doctor stay up-to-date with regard to the latest research on the techniques for managing pain, as this information also informs the treatment plan. For instance, the interventional pain doctor will have expertise in the conditions that each technique has been supported or not supported as an effective treatment by the literature.
As mentioned above, cutting or the resection of nerve fibers is one of the oldest interventional techniques. Generally, this procedure was performed on the nerve fibers that transmit pain information and run longitudinally within the spinal cord. The nerve fibers that transmit pain information to the brain can enter the spinal cord at a variety of locations all along the vertebral column. Additionally, these nerve fibers that transmit pain information generally run together along the spinal cord as they make their way up to the brain. Thus, once the source of pain has been identified, the area on the spinal cord just above this particular nerve can be spliced. Once this is conducted, the individual generally reports experiencing a cessation of pain sensations from any area of the body up to the area of the resection. To understand this process, an illustration using a main phone cable to supply phone service to a row of homes along a straight, dead end road. Each home on this street is supplied with phone service from a cable that branches off from the main cable along the road. If one were to splice the main cable at some location along the street, those homes that are located from where the cable was spliced through the end of the street would lose their phone service. This is a similar process in the body with nerve fibers and the transmission of pain information to the brain. Indeed, this procedure is quite invasive and radical, as well as permanent. It was generally used in cases of refractory pain that had been unresponsive to all other methods of treatment. This procedure is rarely used today.
Interestingly, radiation is another interventional approach that has been used to manage pain that arises from cancer conditions. Cancer-related pain can arise as the result of bone metastases or the compression of nerves as the result of a tumor. In some cases, using a low dose of radiation has caused the individual’s pain to subside. The underlying mechanism to account for this effect, however, is not well understood. More research is necessary in this area so as to more clearly delineate the function of radiation in providing relief from pain in these instances. Further, stimulation of the spinal cord and brain with electrical impulses are another interventional technique for providing pain relief. Pharmacological agents can also be delivered to highly specific areas with the goal of providing relief from pain. For instance, injections of corticosteroids in the epidural area or the intrathecal area (just inside the dura mater) can provide significant and almost immediate relief from refractory pain. Patients with chronic pain may also benefit from these approaches long-term. Indeed, the development of devices that may be implanted to provide pain relief have been shown to be effective in managing debilitating pain for as long as ten years.
What is A Pain Fellowship?
The training required to become a medical doctor has been impacted significantly with the rapid advances that have occurred in the field of science and healthcare. Nonetheless, individuals who wish to apply to medical school are required to have completed a four-year Bachelor’s degree at an accredited institution. The applicant’s coursework for this degree must have included a number of pre-requisite courses (such as chemistry and microbiology). Further, the applicant is required to score above a specified percentage on the standardized entrance exam for medical school. Applying to medical school is a highly selective process and only the top candidates are accepted each year.
Despite the advancement of knowledge, even in the course of the last ten years, medical school programs generally include four to five years of training that is comprised of core courses in relevant subject areas and supervised clinical rotations. A percentage of medical students choose to seek out additional training opportunities immediately following completion of the first phase of medical school. Once a trainee has completed the medical school training program, they typically will complete at least one year of internship. During this time, the trainee is closely supervised and receives specialized training in an area of interest. In order to become licensed to practice medicine, the trainee must complete a required number of supervised practice hours and successfully pass a licensure exam. Many individuals who undergo medical training choose to spend additional time gaining supervised experience in their specialty area. This is known as the medical residency. In fact, nearly all students training in the U.S. complete a program of medical residency that can last anywhere from two to seven years.
Even after successfully completing a residency program, physicians in training have the opportunity to complete a fellowship program. A medical fellowship typically lasts one or more years and, upon completion, prepares the physician to practice independently in that area of specialty. Physicians who wish to practice a specialty independently not only need to complete a specialized fellowship program, but also must successfully pass a board certification exam and an oral certification exam.
In terms of the specialty of pain management, a fellowship program in diagnosing and treating pain conditions will prepare the trainee for becoming certified to practice independently as a pain doctor. Currently, in the U.S. there are a number of medical institutions that offer fellowship programs in the management of pain. A list of these programs can be found on the website for the American Pain Society. Many of these fellowship programs are, indeed, housed within departments of anesthesia. These fellowship programs generally favor applicants who have received their primary training in the areas of Physical Medicine and Rehabilitation, Neurology, Psychiatry, and Anesthesiology. Not surprisingly, residents of anesthesiology programs comprise the largest percentage of applicants to pain management fellowship programs.
The Accreditation Council for Graduate Medical Education (ACGME) offers programs with fellowship training the opportunity to apply for accreditation in the specialty area of pain management. Currently, there are over 100 programs that are ACGME-accredited as pain fellowship programs and most are housed within training or academic research hospitals. During this specialized training, pain fellows spend approximately 12 months within both inpatient and outpatient care settings gaining experience and expertise in the evaluation, diagnosis, and treatment of a wide variety of pain patients. The patients present with pain conditions that are both acute and chronic, and may also include patients struggling with cancer pain.
Owing to the diversity of conditions that cause pain, pain fellows are exposed to the multidisciplinary approach to patient care. This means that the pain fellow gains experience in working with other specialists to provide patients with comprehensive care. During this training, pain fellows gain experience and expertise in employing all interventions currently utilized for effectively managing pain. These interventions include pharmacological, non-pharmacological, implant-based, non-surgical, and surgical interventions. Pain fellows, in particular, gain experience in the advanced procedures that are available for providing patients with pain relief. These include ultrasound-guided injections and nerve blocks, sympathetic blocks, head and neck (cervical) nerve blocks, neuraxial injections and nerve blocks, neurolytic techniques, and headache-specific interventions. As with many other fellowship training programs, pain fellows have the opportunity to participate in regular didactics that include seminars, lectures, and conferences.
In addition to training in assessing, diagnosing, and treating pain conditions, pain fellows have the opportunity to gain training in business aspects and the management of practicing pain medicine. Further, pain fellows are encouraged to participate in ongoing research efforts in the field.
What is Comprehensive Care?
Given the complex nature of pain, a proper comprehensive care plan will involve a variety of different therapeutic methods. The goal of a comprehensive care team is to provide the patient with care that addresses all aspects of their condition. More specifically, once the pain doctor identifies the source of the patient’s pain (frequently in conjunction with a consultation with the patient’s primary care physician), an individual treatment plan is developed for that individual utilizing a multidisciplinary team to provide the patient with the most comprehensive approach to treating their condition. The most effective pain management teams include the pain doctor, anesthesiologists, orthopedic surgeons, occupational therapists, physical therapists, pharmacists, psychologists, and psychiatrists.
A unique feature of comprehensive care using a multidisciplinary team is that the pain management program may be employed within a wide variety of settings. These can include family practices, private practices, hospitals, medical centers, and even the patient’s home. Most of these programs have the capability to provide medication management, psychological treatment, physical therapy, parent education, and even vocational counseling. The goal of each of these individual components is that they target improving the patient’s quality of life and ability to function on a day-to-day basis. As such, each member of these teams has a different function. This improves the quality of care that the patient receives, as they are able to receive highly specialized care of each domain of functioning. The comprehensive care team can also provide the individual with treatment in the areas of psychological, emotional, educational, and social concerns. Difficulties in these areas can exacerbate many conditions that cause pain and also can emerge as the result of ongoing difficulties with pain. Thus, utilizing a comprehensive care model, the healthcare team is able to recognize these issues and provide the patient with care in these areas as well.
There is a large body of literature supporting the multidisciplinary approach for managing both acute and chronic pain. Specifically, this body of literature supports the likelihood of favorable outcomes following this treatment model. Additionally, the multidisciplinary approach to pain management has received support as clinically and cost effective. The reason for this is that reductions in the amount of pain and discomfort—even without removing/relieving it completely—can have a large beneficial impact on the patient’s degree of stress.
The comprehensive care approach has been shown to be particularly successful in cases where opioids have been utilized. More specifically, using opioids to treat pain conditions can bring about additional concerns with regard to abuse and dependency, which may require expert intervention. By having the availability of a comprehensive care team, patients who are prescribed opioids for managing their pain can receive patient education regarding the risk for dependency on this medication, as well as early intervention, should the patient begin to show signs of abuse.
How Does A Pain Doctor Diagnose Your Pain?
Diagnosing pain can be a challenging task. The proper assessment of pain is only the first step in developing an appropriate pain treatment plan. In order to assess pain, most pain doctors will utilize self-reports. More specifically, the pain doctor will gather the patient’s account of recent activity and description of symptoms. This will include any known injuries or events leading up to the onset of symptoms. Further, the pain doctor will also gather information regarding the individual’s medical history, family history, and any other known health problems.
In order to arrive at the most accurate diagnosis, the pain doctor will generally conduct a physical examination in addition to the oral account. This is particularly relevant in instances of injuries due to sports. This exam generally involves an assessment of the individual’s degree of strength, mobility, and flexibility. Additionally, the physical exam will include an in-depth evaluation using a variety of modalities. Most commonly, the pain doctor will conduct a visual examination of the patient, paying particular attention to areas of the body with any obvious signs of pain and discomfort. These signs might include an abnormal posture or a pronounced limp.
Additionally, the pain doctor may conduct a palpation examination. During this procedure, the pain doctor will use their hands to scan the patient and will apply gentle pressure to feel for internal masses, vibrations, pulsations, and skin temperature. Another type of assessment is the percussion. During this type of assessment, the pain doctor will place a hand on the surface of the skin and then, using the other hand, will tap on the top of the hand. The audible vibration produced by this assists the pain doctor in determining the density and size of any underlying structure or organ. An auscultation exam is another type of physical exam that may be performed by a pain doctor. This assessment involves the use of a stethoscope to listen for any abnormal sounds produced by the lungs, heart, and blood vessels.
Pain doctors may conduct other physical exams, such as the range of motion (ROM) exam. This exam is generally performed in order to discern the limits of movement before pain is experienced. Other tests can be conducted in order to aid in the pain doctor’s diagnosis, should the diagnosis be uncertain. These assessments may include magnetic resonance imaging (MRI), X-rays, PET scans, computed tomography (CT) scans, and computed axial tomography (CAT) scans. These techniques have the capability of producing images of internal tissue. Pain doctors can then inspect these images for abnormalities and injury. These imaging techniques are preferred, as they are non-invasive. However, they are limited and in some cases do not readily identify the source of the pain. Procedures such as a discography or myelogram are available to augment these imaging studies and provide pain doctors with useful information in terms of diagnosing the underlying pain condition. These techniques involve the use of contrast dye, generally injected into the intervertebral disc or other area surrounding the spinal cord. This contrast dye then is revealed during the X-ray to provide the pain doctor with a graphic illustration of the area. Radioactive substances may also be used in instances of bone conditions, as these disorders are particularly challenging to diagnose. Once the radioactive material is injected into the bone, a bone scan is then conducted. The results of this test can illustrate possible bone fractures, any bone infections, or other problems within the bone.
The process of diagnosing the underlying pain condition may involve several iterations. More specifically, the pain doctor may arrive at an initial diagnosis and begin treatment accordingly. After assessing the response to this initial treatment, the pain doctor may decide to change the course of the treatment, as information from the response to treatment may indicate that another diagnosis is more appropriate.
How Does A Pain Doctor Manage Your Pain?
The ideal treatment for any given pain condition is developed on an individual basis in order to fully meet the needs of the patient’s unique pain episodes. Thus, the treatment strategies employed within each treatment plan are likely to depend upon the patient’s injury or description of pain and discomfort. Pain doctors employ a wide range of interventions, given that no two episodes of pain are alike.
Currently, there are a number of options available in terms of pharmaceutical interventions for the management of chronic pain. The medications recognized to treat pain at any stage of severity can range from non-steroidal anti-inflammatory drugs (NSAIDs) to the stronger, more potent opioids. For patients who report more mild symptoms of pain, the pain doctor will first recommend using a non-opioid, over-the-counter medication. This type of medication can include either a non-steroidal anti-inflammatory drug (NSAIDs) or acetaminophen. Given that these medications are non-habit forming and generally regarded as safe, they may be taken on a schedule rather than an as-needed basis. This means that patients would take the medication around the clock, rather than wait for the medication to wear off and have the pain return before taking the next dose. The use of NSAIDs long-term, however, has been reported to be associated with an increased risk for gastrointestinal erosion. Pain doctors may also recommend another non-prescription medication to treat mild instances of pain, which is acetaminophen (i.e., Tylenol). This medication does not have any anti-inflammatory benefits, however it does provide an analgesic effect while limiting the patient’s risk for any gastrointestinal problems. Minor cases of pain may also be treated using analgesic patches. These patches contain lidocaine and other chemicals, such as capsaicin, that provide pain-relieving benefits. Your pain doctor will assess whether these types of interventions are sufficient for managing your symptoms of pain.
For more moderate instances of chronic pain, these symptoms may be managed using a schedule of non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen, combined with a weak form of opioid, such as codeine or hydrocodone. Side effects from using opioid medications include nausea, constipation, rash, sedation, respiratory depression, and addiction. Previous work has revealed that patients who were prescribed opioids for the long-term management of pain exhibit signs of a weakened immune system. The majority of opioid medication is administered in an oral fashion; however, there are transdermal patches available. Your pain doctor will likely assess your individual risk for substance abuse prior to prescribing an opioid medication. Further, patients taking opioids are closely monitored for signs of drug abuse. More moderate to severe episodes of chronic pain are best treated using opioid medications. These medications may be administered orally, with a transdermal patch, or even through an intrathecal pump. This pump acts to deliver the drug directly into the spinal fluid, which provides the patient with a significant degree of relief.
Physicians and pain management specialists are afforded a wide array of options in terms of managing chronic pain pharmaceutically. Generally, physicians will consider the effectiveness of the medication being administered, as well as the safety of the drug and its administration method.
Another method for managing pain is the corticosteroid injection. The procedure involves the injection of corticosteroids into the area around the affected nerve to provide the patient with almost immediate relief from pain. This procedure is considered minimally invasive and can be performed on an outpatient basis. Prior to the procedure, the pain doctor thoroughly cleans and preps the skin. Should the patient opt to be sedated during the procedure, the patient’s blood pressure, heart rate, and respiration are monitored throughout. The patient is asked to lie down on their stomach with their back facing toward the pain doctor administering the injection. Generally, a topical anesthetic is applied to the surface of the skin. In order to ensure that the needle has been inserted into the proper area, a small X-ray (or fluoroscopic) device is used as a guide through the vertebrae. The pain doctor may also test that the needle has been properly inserted by injecting a small amount of contrast dye before administering the steroid medication. The use of contrast dye can also assist the pain doctor with ensuring that the proper distribution of the steroid solution will be achieved. The ideal distribution of steroids would include only those areas that have been affected (typically as evidenced by inflammation), so as to reduce the degree of exposure the patient would experience to the steroids.
Other methods for managing pain are also available. These include device implants for managing pain on a long-term basis, spinal cord or spinal nerve stimulation, or even surgery. Your pain doctor will discuss with you the available options for managing your pain, as every episode of pain is different.
Biologically, pain is necessary, as it is the body’s alarm system that something is wrong. The perception of pain is a complex sensory process and emotional experience. Pain is quite common and can range from a dull soreness or ache to a sharp stab. In fact, almost all adults will experience a pain episode at some point in their lives. Some episodes of pain, however, can be so severe or persistent that it begins to interfere with the individual’s ability to perform necessary day-to-day functions. For these individuals, it is strongly recommended that they undergo an initial evaluation with their primary care physician. Individuals with chronic, debilitating pain will likely be referred to a pain specialist, who specializes in the diagnosis, management, and treatment of various pain conditions. Early intervention is recommended, as pain conditions that are not treated or are undertreated have been shown to be associated with worsening outcomes.
There are a large number of treatments available for managing pain that range widely in their degree of invasiveness. These treatments can range from physical therapy and pharmacological treatments to more interventional techniques that include corticosteroid injections or surgery. Given the number of treatments available, the ideal intervention largely depends on the source of the pain, the degree of debilitation, current symptoms and severity, and response to previous interventions, if any. Some treatments are associated with side effects. Indeed, some pain medications are associated with abuse and dependency. Given that pain episodes, particularly chronic pain, can be associated with mental, emotional, and behavioral factors, a multidisciplinary approach is preferred. The multidisciplinary approach is ideal, as it targets treating the whole person with the goal to restore the individual to their previous level of functioning as quickly as possible.
Professional Organizations and Resources
Below is a list of organizations and resources that we recommend you check out in search for more information about your pain.
Accreditation Council for Graduate Medical Education — www.acgme.org
American Academy of Pain Medicine — www.painmed.org
American Board of Anesthesiology — www.theaba.org
American Board of Medical Specialties — www.abms.org
American Board of Pain Medicine — www.abpm.org
American Board of Physical Medicine and Rehabilitation — www.abpmr.org
American Board of Psychiatry and Neurology — www.abpn.com
American Pain Society — www.americanpainsociety.org
American Society of Regional Anesthesia and Pain Medicine — www.asra.com
International Association for the Study of Pain (IASP) — www.iasp-pain.org
Pain Doctor – The Global Pain Knowledge Base — www.paindoctor.com
World Institute of Pain — www.worldinstituteofpain.org
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