The IP Network: A Case for Intractable Pain Centers Part II
In the last issue of Practical Pain Management (September/October 2004, Volume 4, Issue 5), the subject was the Intractable Pain Center — a facility to which family physicians and internists could refer their chronic pain patients whom they classified as suffering from intractable pain. The authors reiterate that the objective of this series is to promote the creation of IP centers in every community in the U.S. Epidemiologic surveys clearly indicate that the number of intractable pain cases in every community warrants an organized network of physicians to provide care.
Every intractable pain center needs to be supported by a network of specialists who can be called upon to provide specific treatment as required. They are not necessarily individuals who reside in the same facility but are part of an established network emanating from the IP center — rather than just a specialist to whom the IP physician spontaneously chooses to refer.
Organizing the IP Network
In an optimum situation, the IP physician selects a number of specialists, contacts them, and invites them to become part of his network. Instructive discussions follow with, perhaps, written documentation of guidelines and procedures. Of utmost importance is for each specialist and the IP physician to have a clear understanding of the indications that trigger the need for the specialist’s expertise. In a section that follows, the authors have outlined the indications for each specialty.
In addition to the network, each IP center requires dedicated ancillary services that are also listed in a subsequent subsection. These services are intended for the use of the IP physician or one of the specialists. For instance, a patient may be referred to a physical therapist by either the IP physician or by the network orthopedic surgeon.
All members of the network will receive a roster of network and ancillary members and will be encouraged to engage in consultations. Although the members of the team will not necessarily be co-located, today’s electronic inter-connectedness can certainly facilitate communications between all network members in what would be a virtual office.
IP Network Roles
In the section that follows, the other network members are listed with the indications that trigger their participation. Note that in some areas of the country, not all the specialists listed may be available and some may have to take on dual roles. With the employment of a network of specialists, the IP physician will be relieved of major concerns about the procedures that are being employed, possible drug abuse, and other inhibiting factors.
IP Physician — The “Gatekeeper”
The IP physician is the manager of the network and manages medications such as opioids, hormonal therapy and other therapies. Many specialists perform pain management and include anesthesiologists and physical medicine specialists. However, with the number of centers needed around the country, it is anticipated that there will be an insufficient number of these specialists willing to take on this role. The authors logically look to family physicians, internists, and other first-line medical practitioners who feel motivated in providing this critical care to IP patients. The IP physician is the manager of the network and, as such, requires knowledge of ancillary support and services.
When there is doubt about the genuine need for aggressive treatment, the psychologist is called upon to evaluate the legitimacy of the pain that dictates the use of potentially abusive drugs and the ability of the patient to accept their lifetime incurable condition.
With any indication or suspicion of drug abuse history, the patient is to be evaluated, and, in some cases, co-managed by the addictionologist network member.
The PM&R network member will evaluate the patient for the necessity of physical therapy and the use of supportive prostheses.
The endocrinologist will be called upon to evaluate and possibly co-manage the hormonal complications of pain and opioid therapy such as hypotestosteronenia, osteoporosis, and adrenal deficiencies.
The neurologist will be called on to evaluate and possibly co-manage such conditions as headaches, neuropathies, and neuralgias.
The rheumotologist evaluates and co-manages auto-immune disorders such as fibromyalgia and systemic lupus erythematosis.
The psychiatrist plays an important role in treating commonly found maladies of IP patients such as depression, attention deficit disorder, and other neuropsychiatric complications of intractable pain treatment.
The neurosurgeon is available to evaluate spinal and nerve disorders to determine if a surgical procedure can be curative or ameliorative.
Bone related disorders are referred to the orthopedic surgeon to determine if a surgical procedure can be curative or ameliorative.
Services such as records administration, dental, legal, home care, pharmacy, podiatry and diagnostic services can provide complementary support that can fill all a patient’s needs. All members of the network will be informed of the available ancillary services and will be expected to employ their services as required. The administrative function is extremely important because it is necessary that records of treatment be maintained at the IP center whether treatment occurred there or at an office of a network participant. Legal support should be an ongoing function reviewing changes in relevant laws, compliance, and advising of potential problems. The records of historic drug abusers should be reviewed by the legal member to avoid any potential problems.
DEA rescinds “Prescription Pain Medications: Frequently Asked Questions and Answers for Health Care Professionals and Law Enforcement Personnel”
In the September/October issue of Practical Pain Management, in a news release on page 54, it was announced that DEA had released a document entitled “Prescription Pain Medications: Frequently Asked Questions and Answers for Health Care Professionals and Law Enforcement Personnel.” The release contained a brief summary of the document and a web site where the document could be accessed.
PPM has received calls from our readers that the document could not be accessed. A recent investigation uncovered the following internet message:
In August 2004, the Drug Enforcement Administration (DEA) published on its Office of Diversion Control Web site a document entitled “Prescription Pain Medications: Frequently Asked Questions and Answers for Health Care Professionals and Law Enforcement Personnel.” The document contained misstatements and has therefore been removed from the DEA Web site. DEA wishes to emphasize that the document was not approved as an official statement of the agency and did not and does not have the force and effect of law.
DEA recognizes that the proper use of controlled substances in the treatment of pain remains an extremely important issue. Accordingly, DEA intends to address this matter in the future.