Pain Medicine Specialists Research Articles

Commentary: Albert Ray, MD

I believe that any physician would be hard pressed to defend the inadequate pain care in this particular case. It is painful to read about the way this poor patient had to spend his final days. The medical management by both Dr. V. and Dr. W showed a poor knowledge of analgesic pharmacology, and unfortunately, neither physician requested a consultation with a pain medicine specialist. The care given by the nursing staffs at both MD and BCC was equally inadequate. In addition to the inadequate state of education in pain care and its obvious reflection in this medical case, another area of concern in the Tomlinson case is the way this matter was handled in the legal arena. A complaint was appropriately filed with the MBC, California DHS, and CMS to deal with the physicians and two facilities that took part in the care of Mr. Tomlinson and were responsible for the inadequate care he received and the suffering he had to endure. However, as pointed out in Ms. Tucker's article, the state medical negligence law in California does not permit “pain and suffering damages” to survive death. “Thus there would be no damages recoverable for Mr. Tomlinson's pain and suffering under a medical negligence claim in California,” according to Ms. Tucker. Rather than live within this law, the plaintiffs' counsel opted to pursue a tort case as elder abuse, which required the plaintiffs to prove recklessness, rather than medical negligence, on the part of the defendants in court. This move was based on a precedent in an earlier case ( Bergman v. Eden Medical Center ). The use of this legal move is the most troublesome part of this case for physicians. I cannot imagine a physician who would not be in agreement with the Tomlinson's family being awarded monetary damages …

Effect of Erbium:YAG Laser Treatment on Scar Pain

Scar pain has persisted as a significant problem for patients who have undergone surgery or suffered trauma. The pain may vary from what is described as irritation or itching to severe neuropathic pain. Recent work by dermatologists using lasers to treat scars for cosmetic reasons has revealed that there has been pain relief from the cosmetic laser treatment. This study examined the effect of a single erbium:YAG laser treatment on 23 patients with chronic (>6 months) scar pain. Assessment was at one month and four months post treatment. Results showed a significant and persistent decrease in McGill Pain Scale, Itch Visual Analog Scale, and Pain Intensity Scale. Treatment of chronic scar pain with readily available cosmetic lasers may be of significant benefit to patients who have not responded to standard injection therapy. This research was funded by the Department of Anesthesiology, LSU Health Sciences Center—Shreveport. Presented in part at the Joint International Laser Conference, September 21-23, 2003, Edinburgh, Scotland. BACKGROUND AND OBJECTIVE Scar pain may persist chronically after surgery or accidental trauma. Entrapment of neurons by collagen has been considered the most probable cause.1 Treatment has included infiltration with local anesthetic agents, steroids, electrical stimulation, and needles, all of which usually provide only short-term relief. An incidental finding in a study of cosmetic laser treatment of scars showed significant pain relief for four patients who also had pain.2 The objective of this study was to examine the effect of a single treatment with an erbium:YAG laser on chronic scar pain. STUDY DESIGN/MATERIALS AND METHODS After approval by the IRB at LSUHSC-Shreveport and informed consent, 23 patients with a history of chronic (>3 months) scar pain were studied. Demographic data collected included age, weight, height, sex, Fitzpatrick Scale (skin color), type of injury (accidental vs surgical), and location of scar. The Fitzpatrick Scale assesses skin color: A score of 1 represents very light skin, and a score of 5 represents very dark skin. Baseline assessments included McGill Pain Score (Figure 1), including sensory and affective pain descriptors, VAS pain scale, VAS itching scale, and a 5-point numerical intensity scale (0=none, 1=mild, 2=discomforting, 3=distressing, 4=horrible, and 5=excruciating). Figure 1 Figure 1: McGill Short Form.3 Yellow are sensory attributes; orange are affective attributes. All patients were treated with an Er:YAG laser (NaturaLaseTM, Focus Medical, Bethel, CT)(Figure 2), wavelength 2.94 nm, fluence 1.29 J/cm, spot size 8 mm, with 2 pulses per second, and 50% overlap. Assessment was at one month and four months post-procedure. Data were analyzed with repeated-measures analysis of variance, and a priori level of significance was defined at p When Manuskiatti, et al, studied the cosmetic effects of lasers on scars, they noted in passing that four of the patients they studied had complained of scar pain prior to the cosmetic treatment, but that after the treatment, the scars not only looked better, but the pain had vanished.2 They used a 585-nm pulsed-dye laser in their study. Kotani, et al1 hypothesized that nerve ending were entrapped by the formation of scar, causing the scar pain. If this is true, the laser could be simply destroying the collagen and causing it to regrow in a manner such that it no longer constricts the nerve ending. Recently, Martin has proposed that the laser may reduce directly chronic inflammation at the cellular level.4 Whatever the physics and physiology, cosmetic lasers are ubiquitous, and their potential application by anesthesiologists and pain medicine specialists to treat chronic scar pain represents a real breakthrough in this difficult area of pain medicine. CONCLUSION The Erb:YAG laser shows significant promise as a treatment modality for chronic scar pain.

Radiographic Imaging for Regional Anesthesia and Pain Management.

Radiographic Imaging for Regional Anesthesia and Pain Management.

Manual of Pain Management, 2nd edition.

Mayo Clinic, Rochester, Minnesota. wong.gilbert@mayo.eduManual of Pain Management, 2nd edition. Edited by Carol A. Warfield, Hilary J. Fausett. Philadelphia, Lippincott Williams and Wilkins, 2002. Pages: 407. Price: $59.95.With the continued growth and interest in the field of pain medicine, there has been a significant increase in the number of available texts on the subject. These written texts have ranged from those focusing on discrete circumscribed areas within the field to large, comprehensive reference textbooks. Furthermore, there is a varying degree of emphasis on research compared to the clinical practice of pain medicine. The text edited by Warfield and Fausett, Manual of Pain Management: Second Edition , attempts to provide a fairly concise review of the clinical practice of pain management geared in a “manual” or “handbook” approach. This new edition joins several other texts currently available that are written in a similar style.In this second edition, the editors have organized chapter contributions from a multidisciplinary group of authors. Though a few chapters touch on the physiologic basis of pain learned from basic research, the primary emphasis of the chapters is on the clinical practice of pain medicine. The organization of the text is divided into the following sections: 1) Understanding Pain, 2) Pain by Anatomic Location, 3) Common Painful Syndromes, and 4) Pain Management, with this fourth section being the major emphasis. Interestingly, there are separate sections on “Pain by Anatomic Location” and “Common Painful Syndromes.” This organization may be helpful in generating differential diagnoses based on location, such as the arm or leg, as one may see in the clinic or hospital setting. However, it becomes difficult to avoid some overlap with the chapters in the section of Common Painful Syndromes. As expected from the title, the largest section of the text is devoted on Pain Management. This major section is divided into the full spectrum of analgesic therapeutic approaches, including Medications, Injection Therapies, Physical Measures, Behavioral Therapies, Surgery, and Considerations in Pain Management. There are some minor contributions on more widely accepted complementary and alternative medicine–based techniques, though not extensive. In applicable chapters, there are often one or several case reports highlighting either the pain assessment process or analgesic treatment utilized. Also, a brief list of references and recommended readings are provided at the end of each chapter.Expectedly, in a multiauthored pain medicine text, there are chapter biases that at times seem to reflect the specialty base of the author of that particular chapter. Some minor instances might include not mentioning a possible diagnosis on the list of differential diagnoses of an anatomic location or the use of an injection therapy approach that may not be commonly used by other pain specialists in the field. However, this multidisciplinary authorship approach does provide a wider spectrum of perspective, which is essential for today's modern practice of pain medicine.In summary, this new edition would most likely serve the needs of resident and fellow trainees engaging in a pain medicine rotation, those preparing for a pain board examination, and clinicians seeking a primer on basic concepts of the clinical practice of pain medicine. This book is not meant to be a comprehensive reference text on pain, and should not be purchased for that purpose. When compared to other books of the same type, I think it is one of the better ones. For those at the training level, the material presented in this text will serve as a useful tool, in conjunction with excellent teaching by attending staff, to cultivate the education and interest of the next generation of pain medicine specialists.

Incompetence, drug diversion or pain management? Trying to draw the line.

For several years, I have been reviewing cases submitted to me by insurance companies, which want to know if the treatments utilized are within the accepted standard of care. I get a modest fee for these reviews, but my main reason for accepting the work is that I usually enjoy doing it. Recently, however, I was sent three cases related to the same practitioner, Dr. X, a self-appointed Pain Medicine specialist somewhere in the Midwest. In reviewing these cases, I found that …

The Role of Guidelines in Interventional Pain Medicine: Let Us Separate Apples and Oranges

Practice guidelines are not only an ancient tradition, but they are a fact of life. The first guidelines were developed in the 1840s, shortly after the use of anesthesia was first demonstrated. Even though practice guideline development has spawned an impressive and over-aggressive literature of its own, many unanswered questions exist with regard not only to practice parameters and guidelines in general, but in particular with the application of interventional techniques in managing persistent pain. In spite of the great potential of clinical practice guidelines, and the involvement of numerous medical societies and physician groups, there is still a great debate within the profession not only about the pros and cons of the development and usage of the guidelines, but also conflicting and controversial opinions on both sides of the issue, i.e., providers and patients vs payors. This article discusses the development, usage, advantages, disadvantages and the implications of practice guidelines to interventional pain medicine specialists.

Financing the treatment of chronic pain: models for risk-sharing among pain medicine physicians, health care payers, and consumers.

Chronic pain patients are among a growing group of medically underserved Americans. Despite increasing public awareness about pain and widespread legislative activity that is focusing on the needs of pain patients, there remain significant roadblocks in bringing the expertise of Pain Medicine specialists to these unfortunate people. This paper explores how the managed care revolution has impacted the practice of Pain Medicine in the United States. The dissolution of many prominent multi-disciplinary pain treatment centers has been paralleled by the evolution of pain management as an area of interest by several competing medical specialty societies. Despite this fragmentation, the American Academy of Pain Medicine continues to grow and to promote the needs of Pain Medicine specialists and their patients. The advantages and disadvantages of various practice patterns for Pain Medicine specialists is explored against a backdrop of discussions about: (1) the problems currently faced by chronic pain patients; (2) the role of organized Pain Medicine in helping patients to access and finance care; and (3) the future of American health care and the new responsibilities that will bring to physicians. Finally, we have some specific recommendations for pain medicine specialists about: (1) sharing risk; (2) exerting individual leadership; and (3) simplifying one's professional life in the new health care environment, that we hope will enable them to continue caring for as many chronic pain patients as possible. It is opined that the development of sophisticated regional specialty networks is the best model to accomplish this task in the future.

A BUSINESS PLAN FOR A PAIN CLINIC

Millions of people suffer from chronic or intractable pain. Persistent pain varies in etiology and presentation. In some cases, symptoms and signs may be evident within a few weeks to a few months after the occurrence of an injury or the onset of disease. The cause of pain is not always known or apparent. For many patients, initial medical evaluation and treatments effectively relieve pain that might otherwise become chronic. Like many illnesses that at one time were not well understood, pain and its many manifestations may be poorly treated and seriously underestimated. Inappropriately treated pain seriously compromises the patient's quality of life, causing emotional suffering and increasing the risk of lost livelihood and social integration. Severe chronic pain affects both the pediatric and adult population, and often leads to mood disorders, including depression and in rare cases, suicide … Each physician bears the responsibility to evaluate and treat persistent pain as a serious medical condition. Principal treatment physicians must approach each patient with respect and urgency and provide appropriate and timely referrals to a pain medicine specialist when primary medical care has not been effective. Such referrals are appropriate because pain medicine specialists can provide a more advanced level of treatment to patients suffering from chronic or intractable pain … As physicians, we are trained to preserve patients' quality of life and relieve their pain and suffering. We must use all available resources to achieve these goals for our patients. (Adapted from the American Academy of Pain Medicine. Position Statement. February, 1997.) Pain management is an emerging discipline emphasizing an interdisciplinary approach with a goal of functional restoration, and reduction of pain and suffering. In 1976, the United States Social Security Administration officially recognized chronic pain as a significant form of morbidity in the aging American population. This decision extended benefits to cover chronic pain and rehabilitative treatment, and produced an explosion of providers and centers dedicated to its mission. More than 300 centers opened their doors that first year. Since that time, a diverse group of pain treatment centers have emerged in communities throughout the United States. In 1998, the American Pain Society reports there are more than 3000 clinical entities with the focus of treating chronic pain in the United States, up from an estimated 1500 centers reported in 1987. 1 Only a fraction of these entities are truly multidisciplinary in orientation. Pain centers are specialized entities set up to evaluate and treat patients with complex, intractable, and disabling problems. In designing a pain practice, it is important to keep the following in mind. A pain center has three customers: the patient, the referring physician, and the payer. Many patients are referred to these specialized entities as the “court of last resort.” Patients with chronic pain are often bitter, having failed under the care of primary medical providers. They are also cynical about spending large amounts of time in doctors' offices. A successful pain center will be designed to put such patients at ease. The facility will be approachable, provide telephone access between patients and care providers around the clock, communicate frequently with other treating physicians, provide comfortable waiting areas, be accessible to transport teams (including ambulances), and generally make patients feel welcome. Referring physicians want to know that their patients are being cared for effectively. Close communication with other treating doctors is also essential. General questions are asked of the pain physician by first-time referring doctors. It is important for the new pain practitioner to be respectful and accurate when responding to these queries. Additionally, payers are interested in cost-effective care. Patients with pain use a great percentage of health care dollars. 2 Payers are concerned about providing quality care in a cost-effective manner. Strategies for demonstrating to the payer outcomes and benefits of pain therapies will need to be rapidly developed. In summary, a successful pain practice will keep all users satisfied (referring physician, patient, and payer).

The pain medicine specialist as a physician-healer.

The pain medicine specialist as a physician-healer.