When Referring Patients, Not All Pain Specialists Are the Same
Question: A family physician has a pain patient who keeps demanding an opioid dosage above his comfort level. He has sent the patient to three pain specialists who have performed epidural injections and nerve blocks. All the pain specialists concur that the patient needs ongoing medical management, but they refer the patient back to the family doctor and tell him to manage the case. What does he do?
Answer: Primary care physicians who realize they need consultation regarding chronic pain patients often do not know that not all pain specialists have similar training and interests. Traditionally, pain specialists began as anesthesiologists who then further specialized in pain management. Their expertise is usually in invasive procedures—epidural injections, nerve blocks, rhizotomy, radiofrequency ablation, surgically implanted spinal cord stimulators, implanted opioid infusion pumps, etc. Some are also comfortable with noninvasive medication management, but others are not. In contrast, pain specialists whose background is medical rather than surgical—such as in internal medicine, neurology, or rheumatology—are more likely to become experts in noninvasive medication management of chronic pain, especially in the appropriate prescribing of opioids for chronic pain.
My own background is in internal medicine, addiction medicine, and noninvasive medication management of chronic pain, but I often was referred patients by primary care practitioners who were seeking consultation specifically regarding invasive procedures. They did not realize that procedures were not part of my pain management. Several years ago, I wrote a paper in this journal in which I described my informal survey of pain clinics in my state.1 I had observed that in several large pain clinics, the anesthesiologists primarily did procedures, while the nurse practitioners and physician assistants had developed expertise in medication management and followed patients who were on opioids.
It behooves primary care providers to understand the scope of practice of the pain specialists in their community. It sounds as if the family physician above was repeatedly referring his patient to anesthesiologist pain specialists when his intention was to transfer management of the patient’s opioid regimen to a specialist in noninvasive medication management who would be more comfortable with prescribing higher opioid doses than the primary care provider wanted to do. He needs to refer the patient to the appropriate pain specialist, someone who is comfortable evaluating the patient’s medication regimen and adjusting as needed.
Jennifer Schneider, MD, PhD
Internal Medicine, Addiction Medicine, and Pain Management