The US Congress has declared the current decade "The Decade of Pain Control and Research". In addition, The Joint Commission of Health Care Organizations in charge of hospitals has mandated a list of ten standards to make sure every hospitalized patient is evaluated and treated for their pain. According to these new JCAHO standards. Pain must be monitored in hospitals and treated as "The Fifth Vital Sign" along with blood pressure, height, weight, temperature etc. Not properly treating pain can now be grounds for a lawsuit!

Ideally the chronic pain patient is managed by a team of specialists the so called "Multidisciplinary" approach, but in reality this is not feasible or cost effective. The patient and the primacy doctor must choose the best method for the patients not only weighing the risks and the benefit but also his ability to pay for long term care.

The Surgeons:
Orthopedic or Neuro have the same last name. Their treatments can range from laminectomies and fusion to disk replacements. Their job in pain management is to surgically try to restore the normal anatomy and alleviate nerve inpingement. Besides the high cost there is the risk of the surgery and the added risk of the anesthesia. Their success rate of surgery is high in certain procedures (spinal stenosis) done by certain doctors in certain hospitals and poor in others. Repeat procedures, when the first one fails, dramatically diminish their success rate. Even if the surgery is a "success" the patient can still develop chronic pain. This is called Failed Back Syndrome. (This is a large part of my practice). Surgery is always the option of last resort.

The Interventional Pain Doctors
These newer procedures are usually done by specially trained anesthesiologists. These doctors use injection therapies that target the vertebral facet joints or the damaged disk. Treatments range from epidurals with cortisone to nerve ablations and blocks to morphine pumps and spinal stimulation with implantable devices. These procedures are done with needle probes under direct visualization with x-ray fluoroscopy. As with all new procedures, their success rate depends with whom you talk to. The risk factor is minimal but procedures give short term relief and frequently need to be repeated. The morphine pumps and spinal stimulators are extremely difficult and expensive to maintain.

Physical and Psychological Rehabilitation -Chiropractors
First do no harm!
Manipulation, adjustments, electrical stimulation, traction, acupuncture, acupressure, massages, temperature, exercises, nutritional therapies, psychotherapy, biofeedback etc. These techniques can help the great majority of patients recuperate mobility, help cope with their disability and reduce discomfort without risk. Duration of chronic pain relief usually is short unless the patient embarks on a long-term lifestyle change program.

Doctors Note:
I have experience with all the physical rehabilitation techniques and still use some in my office. I am greatly impressed with the results of traction techniques. I rely on the Inversion Table and Spinal Decompression Table (see link). My patients swear by them, especially when combined with occasional muscle trigger point injections.

MEDICAL PAIN MANAGEMENT DOCTORS.

A new breed of subspecialist has arrived driven by the great demand of undertreated pain patients and the advances in newer medications. Medical Pain Doctors maintain their patients with an assortment of FDA approved medications to relieve pain and inflamation. These medications are combinations of the following: Non-steroidal aintiinflamatories (NSAIDS's), morphine based Opioids analgesics, Centrally acting analgesics, anti-convulsivants, sleeping aids, antianxiety agents. dopamine and serotonine agonists or antagonists, antidepressants, acupuncture, steroids oral or injectable, muscle trigger point injections, intraarticular injections, Buprenorphine, topical anesthetics etc. Treating patients with such wide array of medications and different mechanisms of action and side effects requires expertise in the field plus a healthy dose of skepticism of "New Wonder Drugs" (see Vioxx) There is however new promising research in this emerging field, In Fibromyalgia, for example, several recent FDA approvals have been made for the treatment of these chronic pain syndromes. Adding to the difficulty of Medical Pain Doctors, It is also the physicians responsibility to be on the lookout for those few patients that have shown propensity to share, loose, sell, abuse, self medicate, doctor shop or give abnormal urine tests that show illicit recreational drugs. These patients risk their heath and break the law. Ultimately they make it harder for legitimate patients to get their medications. This illegal drug trade is mostly caused by the Internet but also partially caused by "Doctor Shoppers". These "legitimate" patients go to multiple doctors to get medications, which they then sell. There is an urgent need to pass pending laws in Florida that allow pharmacies to share patient information. Other states have successfully enacted these laws. These laws will dramatically put a stop to "Doctor Shopping" in Florida. The Federation of Medical Boards of the United States sets the standards of treatment that physicians must follow. These laws were last updated in April 2003 to ensure currency and adequate attention to the undertreatment of pain. This is called "The Model Policy". www. fsmb.org This Model Policy states the following: that the medical board views pain management to be important and integral to the practice of medicine: that Opioid analgesics may be necessary for the relief of pain: that the use of Opioids for other than legitimate medical purposes can be dangerous and that the physician has the responsibility of minimizing the risk of abuse; and that the physician will not be sanctioned solely for prescribing Opioid analgesics for legitimate medical purposes.