Pain Doctor

According to writings dating back to ancient history, symptoms of pain and discomfort have plagued mankind. These writings give indication of how much humans have suffered from symptoms of pain over the years. Pain itself is quite difficult to describe. The International Association for the Study of Pain defines pain as, “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Describing what makes these symptoms so unpleasant can also be difficult. Symptoms of pain and discomfort vary widely.

It is believed that humans have greater intense reactions to pain sensations than do other animals because they are impacted by psychological, behavioral, and emotional responses as well. It is not surprising to many that sometimes the individual’s symptoms of pain do not match the degree of tissue damage or the severity of the injury. Sometimes, even the smallest surface wound, such as a shallow cut or abrasion on the skin, can lead to very intense sensations of excruciating pain. Moreover, symptoms of pain and discomfort are quite subjective and children learn how to communicate about their symptom of discomfort at a very early age. Some have suggested that these early experiences may even shape the way that an individual experiences pain later in life.

“The aim of the wise is not to secure pleasure, but to avoid pain.” ― Aristotle

The individual’s experience of pain is particularly crucial, as symptoms of pain and discomfort are most often reported as the reason for seeking treatment in the first place. These symptoms are often the only indication of an underlying problem, providing motivation for the individual to make an appointment with their physician to find out the cause of their symptoms. There are times, however, when pain signals are faulty. This occurs when the pain signal alarms continue to go off even when there is no serious underlying condition to treat. What’s worse is that these faulty signals of pain may continue for so long that they become quite debilitating and begin to interfere with the individual’s quality of life.

Individuals who are suffering from symptoms of debilitating or refractory pain are encouraged to visit with their primary health care provider, as a referral to a pain doctor may be warranted. Pain doctors have undergone specialized training in the assessment, treatment, and management of pain conditions. Pain doctors are highly skilled in using a variety of treatment interventions for reducing or even completely eliminating symptoms of pain directly at their source. This article provides an overview on the role of a pain doctor. It will briefly review what specifies an interventional pain doctor, reviews the training required to become a pain doctor, and defines what types of care these specialists are able to provide. Finally, this article will outline the various methods used by pain doctors for treating and managing pain, including physical therapy, heat or ice therapy, oral pain medications, analgesic injections, and nerve blocks.

What Is A Pain Doctor?

Allopathic medicine is a rapidly growing field. Indeed, it is nearly as vast and complex as the human body itself. Given this, it is not surprising that training to become a physician can be quite a time consuming and rigorous process. Making this even more complicated is the fact that technological advances are being made every single day. This creates a problem not only for medical trainees themselves, but also for practicing physicians as they attempt to stay abreast of the rapid changes that are occurring. In some instances, physicians will choose a specialty area, in which they receive more specialized training that allows them to have a more focused view in terms of staying current with advances within the field.

Physicians interested in specializing in an area of medicine can typically do this following completion of their formalized general medical training. Indeed, primary care physicians, who are required to know “a little bit of everything” are regarded as being in the toughest position, because they must keep up with advances in nearly every aspect of medicine in order to appropriately monitor the overall health of their patients. This means, however, that when a primary care physician encounters a condition that they know very little about or that they are unsure how to manage, they are likely to refer the patient to a specialist in the area who would know more about assessing and treating the condition.

For many physicians, specializing has a number of attractive advantages. One of the greatest advantages of developing a specialized area of training and practice is that, as noted above, they have the ability to remain current on technological advances. Thus, physicians with specialized training are able to provide the most well-informed patient care in that specialty area. One area of specialty, which is discussed in this article, is pain management.

The terms pain management and pain medicine are regularly used interchangeably. Pain management is one area in which a physician may choose to develop a more specialized area of training. As described above, the condition of pain has been an area of concern since the beginning of written language; interestingly though, pain management, as a medical specialty is still regarded as fairly new. In fact, the field of pain management dates back to only the late 1980s and early 1990s. Prior to this, the physicians who practiced pain medicine were generally anesthesiologists who did this on the side, in addition to their general practice of anesthesiology. Given that these anesthesiologists were practicing pain management of chronic pain conditions on the side, their goal was typically only to manage the symptoms, rather than treat the source of the pain.

Since the emergence of pain management specialty training sites, there has been an increase in the availability of pain doctors who specialize in assessing, treating, and managing symptoms of pain. Indeed, the role of a pain doctor is to assess, diagnose, and treat symptoms of pain and discomfort; as such, an individual’s pain doctor should never be regarded as replacing their primary health care provider. In fact, an individual’s pain doctor will often rely upon their primary care physician for critical information regarding the individual’s past medical history, current pain symptoms, and course of the condition. The pain doctor then uses this information to help formulate their diagnosis. Information is also gathered from other diagnostic tools, the physical examination, and an interview with the patient regarding the course of the condition to develop the most accurate diagnosis. Most pain doctors are equipped with the most up-to-date tools for treating acute (intermittent or short-term) or chronic (intractable and long-term) conditions that lead to symptoms of pain and discomfort. It is not uncommon for your pain doctor to work very closely with your primary care physician during the entire course of treatment.

Most pain doctors have an in-depth understanding of the conditions that underlie pain, in order to properly diagnose, treat, and manage the individual’s symptoms. Pain doctors are required to understand a wide variety of pain conditions, which include neuropathic, nociceptive, psychogenic, incident, and some less common types of pain that are associated in particular with specific health conditions. These include:

  • Neuropathic pain: Neuropathic pain is thought to emerge as the result of abnormal stimulation of the nerve fibers within the body that transmit non-pain information, such as the position of the body or pressure.
  • Nociceptive pain: The emergence of nociceptive pain is believed to be linked with irritation or damage occurring to the nerve fibers of the body that transmit information pertaining to injurious, thermal, or noxious pain.
  • Incident pain: Incident pain is believed to be associated with aggravating a sore or achy joint, or by applying pressure to a wound or bruise.
  • Psychogenic pain: Psychogenic pain is pain that is exacerbated by a number of different psychological factors, such as emotional, behavioral, or mental factors. These “mind over matter” types of pain can occur as stomachaches or nausea in relation to anxiety or even headaches or other body aches in relation to depression.
  • Other types of pain: These types of pain occur less frequently, but include cancer pain and phantom limb pain reported by amputee patients.

Pain doctors must possess skills and expertise in assessing and effectively treating all types of pain, including symptoms of pain and discomfort arising from acute and chronic conditions.

What Is An Interventional Pain Doctor?

An interventional pain doctor refers to a specific type of pain specialist, practicing a subspecialty of pain medicine. The subspecialty of interventional techniques includes those techniques that are more substantial and even sometimes invasive for treating and managing various pain conditions.

One of the oldest interventional techniques available to pain management is the technique of splicing or re-sectioning the neural fiber of the pain tract. This pain fiber tract runs longitudinally along the spinal cord. Indeed, all nerve fibers transmitting pain information enter the spinal cord along the spinal column, which is also known as the vertebral column. The neural fibers, which carry pain signals to the spinal cord and brain, generally are found to run along these areas together. As such, it is fairly easy for a pain doctor to identify the source of the pain and to treat the symptoms of pain and discomfort. Interrupting the transmission of these signals to the spinal cord and brain essentially treats the symptoms of pain and discomfort. This procedure can lead to significant reductions in or even complete relief of pain sensations throughout the body.

As an illustration, imagine a row of homes along a straight road that comes to a dead end. Along the road, there is one main phone cable that runs down along the street. Each house receives phone service from this main cable, by connecting through a branch off of the main line. If the cable were to be cut somewhere along the road, then all of the houses from where the cable is spliced to the end of the road lose phone service. This same principal applies to splices in the pain fibers of the spinal cord. As such, information transferred from connections below the cut does not reach the spinal cord and brain as the pathway has been interrupted. The pain doctor must be careful when cutting these neural fibers, as they must be sure to slice only those that transmit pain information. The pain doctor must avoid cutting the neural fibers that control the motor nerves. This means that the individual may still be capable of motor reflex responses, even though they may not be able to feel any sort of pain sensation from the areas. In most cases, this type of intervention is regarded as a last resort only after all other methods for providing pain relief have failed.

Pain doctors in the field of interventional pain management have at their disposal a wide variety of advanced and sophisticated techniques, which vary in their level of invasiveness and permanence, for the assessment and treatment of a variety of pain conditions. When the pain doctor is deciding on the appropriate treatment option, they generally take into consideration the individual’s particular underlying condition. For example, cancer-related pain that arises as the result of tumor-related neural fiber compression or even bone metastases can be effectively managed with radiation therapy. For this technique, low doses of radiation are delivered to a targeted area, which ablate the irritated or inflamed sensory nerves. This can produce pain-relieving benefits, though; the precise mechanisms that account for why this technique is so effective are not fully understood.

Other techniques, such as deep brain electrical stimulation and spinal cord stimulation, may be utilized by pain doctors for managing non-cancer related pain. Your pain doctor may first, however, recommend a trial of a more conservative treatment method prior to these more interventional approaches. For instance, your pain doctor may recommend a trial of oral pain medications first, as a temporary treatment for pain and discomfort. These medications may include over-the-counter (OTC) analgesics, such as non-steroidal anti-inflammatory drugs (NSAIDs; for example ibuprofen or naproxen), to prescription pain relievers, such as opioid drugs. Should this trial of oral medications be ineffective in providing pain relief, aesthetic medications may also be delivered directly to the area of the affected nerves, using both epidural or intrathecal injections. These techniques use an injection needle to deliver the medication directly to the affected area in order to provide a more targeted approach to providing relief from pain. With such a variety of tools at their disposal, a pain doctor is able to treat a wide variety of pain conditions.

What Is A Pain Fellowship?

The program for medical training in the United States and Canada can span multiple years. Prior to applying to medical school, students must complete a four-year bachelor’s degree at an accredited college or university. Medical school applicants are required to complete a specialized set of core coursework prior to applying to medical school that can take around three years to complete. Moreover, applicants must have taken and scored very well on the generalized medical school entrance exam. The application and selection process for medical school is quite rigorous, and only the top most talented applicants from around the world are generally selected.

Following completion of a bachelor’s degree and successful admittance into medical school, programs for medical training typically take between four and five years of continuous training. These programs include coursework in the core subjects for the first half of training and clinical rotations for the second half. During clinical rotations, medical students receive hands-on experience, as well as close supervision from an attending physician.

Given that most medical school programs provide only a broad range of medical training over the many topics of human health, a portion of medical student trainees may wish to receive additional, more specialized training. This can be done once a medical student successfully completes the core coursework and clinical rotations required for medical school. Following this, the medical trainee will then begin their specialized internship. This internship generally lasts for 12 months, but may transition into the trainee’s residency training. During this point in training, medical students have had their degrees conferred but have not been fully licensed to practice medicine without supervision.

After successfully completing their internship the medical trainee is then permitted to take the licensing exam. Once they have successfully passed this exam, they may begin to practice medicine independently as a general practitioner. Even at this point in training, many physicians choose to seek additional supervised experience in an area of specialty during what is called a medical residency. Within the U.S., nearly all trainees in medical school complete a residency and this portion of training can span between two to seven years.

Following completion of residency, a small portion of trained physicians may even wish to seek out greater specialized training by completing a fellowship with an accredited program within their specialized field. In general, fellowship programs last one or more years. During this time, the trained physician is certified to practice as an attending or consulting physician in general medicine, while they continue to receive specialized supervision in an area of their choice. Once the trained physician completes the specialized fellowship program, they are then able to practice independently within that area of specialty. In fact, it is not uncommon for the specialty area to require board certification following completion of the fellowship program. In many cases, board certification can include both written and oral exams.

During a pain fellowship, a physician is able to learn the skills necessary to specialize in pain management or pain medicine. As noted above, the fellowship is typically the last stage in a physician’s training. Once the pain doctor has finished a pain fellowship program, they are well prepared for becoming certified and practicing as an independent physician specializing in pain management. There are several academic medical institutions within the United States who offer pain management fellowship programs and most of these institutions are housed within anesthesia departments. In fact, the full list of domestic pain fellowship programs can be found on the American Pain Society’s website.

In general, fellowship programs specializing in pain management tend to consider applicants with prior experience in the specialty areas of physical medicine and rehabilitation, anesthesia, neurology, and psychiatry, and most pain fellowship programs only accept a small number of medical fellows each year. For the most part, fellowship programs will enroll classes of around one to three students, so it is not surprising that admission into these fellowship programs is highly competitive. A small number of fellowship programs have been known to offer a second year of training to those fellows who performed well in the program during their first year.

Given the nature of the curriculum, many pain fellowship programs are set within academic research and training institutions. Moreover, these programs receive their accreditation from the Accreditation Council for Graduate Medical Examination. Currently, there are over 100 ACGME-accredited fellowship programs and a large percentage of these programs are in anesthesia, with a smaller portion of the programs (about 10 to 20%) in other areas, such as rehabilitation and physical medicine. These fellowship programs generally span 12 months and the physician will complete training in both in- and outpatient care. The focus of this training is in the accurate assessment and treatment of a variety of pain conditions. These conditions may be associated with symptoms of acute, chronic, or even cancer pain.

Indeed, there are a wide variety of conditions leading to symptoms of pain and discomfort. This means that a pain fellow must gain experience working within a multidisciplinary environment. Within this multidisciplinary environment, pain fellows learn skills necessary in consultation and liaison with other disciplines, including surgeons or neurologists. Pain fellowship trainees also learn the utilization of a number of different treatment modalities for managing pain. These modalities can include non-surgical, surgical, pharmacological, non-pharmacological, and implant-based methods for managing pain.

The primary goal of a trainee within a pain fellowship program is to be provided with a breadth of experience in both the basic and advanced techniques for managing pain. These techniques include neurolytic techniques, sympathetic blocks, head and neck blocks, ultrasound guided injections and blocks, neuraxial injections and blocks, and headache specific management procedures. Pain fellowship trainees generally also participate in other training activities, which include didactics, lectures, seminars, and professional conferences. Indeed, the fellowship year tends to be quite busy for many trainees.

Pain fellowship trainees are also provided the opportunity to learn basic business and management skill as part of practicing pain management. Moreover, pain fellowship trainees are also encouraged to participate in ongoing research projects, as available. The goal of these pain fellowship programs is to prepare physicians for success within a demanding career specializing in pain management. Further, these programs ensure that the physician is well prepared in order to earn the necessary board certification to practice pain medicine independently. In fact, one distinction of a physician who has completed a pain fellowship program is certification by the American Board of Anesthesiology. More specifically, these physicians have received the Certificate of Added Qualification in Pain Management. Patients who are interested in pain management for their chronic pain condition are encouraged to review the credentials of their potential pain doctor.

What Is Comprehensive Care?

In the area of pain medicine, the term comprehensive care is used to summarize the process behind a complex and multidisciplinary evaluation and treatment plan for a specific health concern for which a patient is seeking care. More specifically, comprehensive care focuses on providing the patient with health care while taking into consideration the patient’s broader overall health and wellbeing. Thus, comprehensive care treatment teams tend to place more emphasis on the role of comorbidities in terms of the current condition and the development of an appropriate treatment plan. Comorbidities are other conditions that may occur concurrent to the presenting condition.

Given that comprehensive care tends to be more inclusive in terms of the considerations, it does not utilize a reductionist approach. A reductionist approach tends to isolate and treat conditions on an individual basis, rather than consider how these conditions may impact one another. It is believed that by isolating and treating only individual health conditions without regard for how they may be impacting one another, the physician may have limited success in terms of treating the condition. Indeed, even if the other health conditions that the patient suffers from appear to fall outside of the causal pathway of the current condition, it is likely that they will have an impact. As an example, many chronic conditions, such as kidney disease, diabetes mellitus, or cardiovascular disease, are taken into consideration when evaluating and treating specific pain conditions, such as sore and aching joints. It should be noted that while these more chronic medical conditions do not generally cause sore and achy joints, they are thought to lead to or exacerbate other conditions, and thus contribute to the individual’s symptoms of sore and achy joints.

There are many physicians who believe that by not using a comprehensive care approach, the treatment plan may only be able to achieve temporary pain relief until the full problem has been considered. Thus, through a comprehensive care approach, the patient’s treatment plan is likely to include several short-term treatment goals for achieving relief from the pain and discomfort from the condition, as well as long-term treatment goals for improving the patient’s overall health and, ideally, preventing the symptoms of pain from returning. Your pain doctor will likely want to monitor progress of your symptoms toward the final goal of overall health by using a variety of assessments and quantitative measures. In general, patients who present with one or more chronic medical conditions will be referred to other medical specialists in order to provide the patient with the most effective overall comprehensive care.

One area in which a comprehensive care team approach for pain management is particularly beneficial is in the pharmacological management of pain. More specifically, one challenge facing pain doctors is balancing the use of opioid medications and drug addiction. Opioid medications are highly addictive; thus, when they are prescribed for pain management they need to be very closely monitored by a pain doctor and other specialists on the comprehensive care management team. In fact, before an opioid medication is prescribed, it is best to clearly define a goal for the pain management and specific plan for when to discontinue the use of the medication.

How Does A Pain Doctor Diagnose Your Pain?

The first goal of the initial visit with a pain doctor is to arrive at a proper diagnosis. Sometimes, your pain doctor may wish to work with your primary care physician. This will allow your pain doctor to gather information regarding your medical history, overall health, and history of current condition. Your pain doctor will also interview you directly about your personal health history. This information will assist the pain doctor in arriving at an appropriate diagnosis for the underlying cause of the pain. You can also expect that your pain doctor will perform an in-depth physical examination. This will include detailed questions regarding the location of the pain, duration, intensity, and any variables that may seem to aggravate or alleviate the pain.

In addition to this information, your pain doctor may decide to order tests like blood draws or even X-rays. In fact, there are several types of imaging techniques that may be used for diagnosing pain conditions. These include magnetic resonance imaging (MRI), computed tomography (CT) scan, or computed axial tomography (CAT) scan. A portion of these imaging techniques uses radiation (i.e., the CT or the CAT scans), while another portion uses electromagnetism (MRI). In both instances, the goal is to develop a high-resolution image of the internal structures of the body. Your pain doctor will review these images for any abnormalities or injuries. Similarly, ultrasound devices may be employed for imaging the internal structures of the body.

There are other types of imaging techniques that involve the use of injecting a contrast dye, which include myelogram and discography. Both of these techniques can provide more in-depth information from a simple X-ray by injecting a contrast dye into the intervertebral disc or area of the spinal cord and spinal nerves near the region of reported pain. Indeed, conditions that affect the bone are somewhat more difficult to diagnose. In these instances, your pain doctor may wish to order a bone scan, which utilizes a radioactive substance to provide a detailed image of the internal bone tissue. Images from bone scans allow pain doctors to identify infections, bone fractures, or other conditions that affect bone tissue. These imaging techniques are important tools included in the entire toolkit that pain doctors use for diagnosing the various underlying conditions that lead to symptoms of pain and discomfort. An accurate diagnosis is essential in order for the pain specialist to develop an appropriate and effective treatment plan.

It should be noted that diagnosing an individual’s pain condition can be an iterative process. In other words, the pain doctor may formulate an initial diagnosis of the pain and begin a comprehensive treatment plan accordingly. During the treatment process, the pain doctor will monitor the patient’s symptoms. The change (or even lack of change) in symptoms following the implementation of a treatment plan can, in fact, provide the pain doctor with critical diagnostic information. Moreover, depending on the effectiveness of the treatment plan, your pain doctor may choose to change the initial diagnosis, as well as the course of the treatment.

Occasionally, your pain doctor will wish to order evaluations by other specialists in the area. These evaluations can include specialists, such as a neurologist or a psychiatrist. These physicians will then share information in an effort to refine the patient’s diagnosis and to provide the patient with a more comprehensive treatment care plan. In most instances, it is possible to identify the underlying source of the pain and discomfort, and, as such, can be effectively treated. A proper diagnosis, indeed, is the important initial step in this process.

How Does A Pain Doctor Manage Your Pain?

The treatment plan for managing symptoms of chronic or refractory pain generally utilizes a comprehensive care approach. This means that your pain doctor will coordinate the effort of a large treatment team containing specialists from many different areas of medicine. Your pain doctor will use information gathered from each member to develop an individualized treatment plan. Indeed, the job of the pain doctor on this comprehensive care treatment team is a complex one. Moreover, the role of your pain doctor is generally not complete once they have arrived at a diagnosis. In fact, once this initial diagnosis has been made, your pain doctor will likely want to monitor the effectiveness of the intervention chosen. Not only do they want to ensure that you don’t have any adverse side effects, but they will be able to gather lots of useful information in terms of the precise underlying condition depending on the effectiveness of the chosen intervention. Further, your pain doctor may also want to change the initial diagnosis, depending on the effectiveness of the treatment plan.

There are a number of different treatment options available for individuals suffering from symptoms of refractory or unremitting chronic pain and discomfort. For the first line of treatment, many pain specialists will want to ensure that you have attempted some of the more conservative approaches. These treatment options include physical therapy, heat therapy, ice therapy, or even just resting the affected area. Other first line treatments include over-the-counter oral medication for pain relief, such as a non-steroidal anti-inflammatory drug like ibuprofen or naproxen. If the patient does not achieve relief from symptoms following a trial of these more conservative methods, then your pain doctor may recommend a more interventional approach.

Only your pain doctor will know if it is appropriate for you to undergo a trial of these types of interventions. First, your pain doctor may recommend that you undergo a trial of stronger prescription oral analgesics, such as opioids, for the short-term management of your symptoms. Further, other possible interventional approaches to treating pain may include epidural injections, in which an analgesic drug is injected directly to the affected area. These injections usually include anxiolytics, anesthetics, or steroidal anti-inflammatory drugs.

In some instances, patients who are followed by a pain doctor and are receiving treatment for a chronic pain condition may be referred for an evaluation by a psychologist or psychiatrist. Moreover, their comprehensive care treatment team may feel that the patient is an appropriate candidate to receive treatment in the form of other alternative approaches, such as homeopathic medications, acupuncture, or chiropractic care. In most cases, these types of interventions are recommended as a complementary approach to be tried in conjunction with a primary treatment plan and other alternative methods. Your pain doctor will discuss the available options with you and recommend what is best suited for treating your particular pain condition.

Conclusion

The experience of pain is a very complex sensory experience that involves other aspects of functioning, such as behavioral, emotional, and cognition. Moreover, difficulty with pain can be experienced by anyone at any time during their lives. In most cases, pain can be treated with at-home methods; however, when symptoms of pain are persistent, do not respond to traditional treatment methods, and begin to have a detrimental impact on the individual’s day-to-day functioning, then it may be time for the individual to seek help from a pain doctor.

Pain doctors receive specialized, formal training in the assessment, treatment, and management of a wide variety of pain conditions. These individuals also receive specialized training in recognizing the impact of other areas of functioning on the individual’s current pain condition. Individuals who believe that they may benefit from a more interventional approach to managing their symptoms of chronic pain, may wish to speak with their primary case physician about a referral to see a pain specialist. It is possible that you may benefit from the comprehensive care provided by the specialists on these teams.

Professional Organizations And Resources

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