The ABC's of Pain Clinic Referrals
“Refer a patient to a pain clinic when your pain on seeing the patient’s name on your daily schedule is a pain you perceive to be greater than the patient’s” has been my sound bite response to questions from colleagues regarding this issue. This article is an attempt to more seriously and completely address a somewhat confusing and perplexing area of medical practice and one in which the volume of patients can be substantial.
Referral: “A Mystery Process”
Patient referrals to pain clinics remains a somewhat enigmatic process for many primary care physicians and for specialists, as well. Most physicians never had exposure to a pain clinic while in medical school, or residency and basic understanding of what goes on within a clinic is limited. The referral can become somewhat of a “black box” referral.
Obviously, for many types of pain and/or discomfort, physicians recognize, or at least suspect, the organ system involved. They can then take appropriate action themselves or refer the patient to a specialist they designate for the problem.
However, pain that continues beyond the time of healing of a particular illness or injury or which occurs for unknown reasons, is the type of pain which frustrates both physicians and patients attempting to find a solution. It is important to recognize that our current state of knowledge in the neurobiology of pain points to a particular organ system as the offending party. The central nervous system, primarily, and the peripheral nervous system, to an extent, have been found to have numerous pathological processes which can perpetuate a signal of tissue damage in the absence of tissue injuries — pain without injury or illness.
The pain itself often leads to other physiologic changes — blood pressure, pulse, certain hormonal changes, as well as the well-observed emotional/affective changes and postural/neuromusculoskeletal changes.1 Behavioral changes may be manifested in increased anger, depression, medical management and disruption of the medical practice environment.
Types of Pain Specialists
The various pathologic changes in the nervous system have led to a kind of ad hoc development of a variety of pain specialists focusing on particular aspects of intractable pain and particular approaches to treatment. These approaches can roughly be divided as follows:
- Interventional Procedures
- Rehabilitation Management and
- Medication Management
- Palliative Care
Interventional procedures involve neural blockade, neural ablation, implantable devices — all usually done by anesthesiologists or physiatrists trained in these approaches.
Rehabilitation management involves a multidisciplinary approach using physicians, psychologists and physical therapists in a team and a program approach focused on increasing function.
Medical management involves the use of medications, often opioids, frequently at dosage levels which are not in the comfort range of the non-pain specialist. The goal of medication management is a reduction of pain to a level which, as with rehabilitation approaches, allow for an increase in function.
Palliative care may involve any or all of the above but is often focused less on functional gain and more on improved comfort in end-of-life situations.
It is essential to note that there is overlap in all of the above approaches.2 Interventional specialists are called on to assist during rehabilitation, medical management and palliative care cases and interventional specialties often include medical management in their practice. Rehabilitation approaches may involve medical management as an aide to decrease pain and increase function. Typical strategies in addressing a patient’s pain-related issues are summarized in Table 1.
Who Does What
Our present ad hoc system of pain care thus presents an initially confusing array of referral destinations for patients. This may be considerably simplified with a little knowledge of the system, a good knowledge of the patient and a modicum of common sense.3 Common sense comes in to play first. If a physician already has a pain physician of any type with whom he/she works and that physician is managing these referrals well in a way in which the patient and referring physician are satisfied, then the “if it ain’t broke, don’t fix it” adage applies well.
While medical awareness of the patient’s history and presentation plays a role in the referral decision, the following outlines certain other key considerations: