The Smart Patient's Guide to
Chronic Pain Management

Your First Visit to a Pain Clinic

If you live with chronic pain, you likely need a team of doctors to achieve an optimal outcome. Here’s what to expect from a pain specialty practice or clinic.

 

So you’ve decided it’s time to make an appointment with a pain physician, or at a pain clinic. Here’s what you need to know before scheduling your visit—and what to expect once you’re there.

What Is a Pain Physician?

Pain physicians, or pain specialists, are experts in the prevention, assessment, and treatment of pain. “Pain physicians come from many different educational backgrounds,” says Dmitry M. Arbuck, MD, president and medical director of the Indiana Polyclinic in Indianapolis, a pain management clinic. Dr. Arbuck is certified by the American Academy of Pain Management and the American Board of Psychiatry and Neurology. “Any doctor from any specialty—for instance, emergency medicine, family practice, neurology—may be a pain physician.”

The pain physician you see will depend on your symptoms, diagnosis, and needs. “Chronic pain is an especially wide field,” Dr. Arbuck explains. “The doctors within a pain management clinic or practice might specialize in rheumatology, orthopedics, gastroenterology, psychiatry,” or other areas, for example.

Pain physicians have earned the title of MD (Doctor of Medicine) or DO (Doctor of Osteopathic Medicine). Some pain physicians are fellowship-trained, meaning they received post-residency training in this sub-specialty. Pain fellowships often emphasize interventional pain treatments, which typically involve injections (eg, nerve blocks), spinal cord stimulation through an implanted device, or insertion of a morphine pump in to the intrathecal space of the spine. (Read more about interventional pain approaches.) 

Pain physicians who have met certain qualifications—including completing a residency or fellowship and passing a written exam—are considered to be board-certified. Many pain doctors are dual-board certified in, for instance, anesthesiology and palliative medicine. However, not all pain physicians are board-certified or have formal training in pain medicine, but that doesn’t mean you shouldn’t consult them, says Dr. Arbuck: “Some of these doctors are really good!”

Image courtesy of the Indiana Polyclinic, a multidisciplinary pain clinic in Indianapolis.

What Is a Pain Clinic?                                      

The term “clinic” often refers to an outpatient medical facility staffed by multiple doctors and other health professionals.

Dr. Arbuck recommends that individuals seeking help for chronic pain see physicians at a clinic or a group practice because “no one specialist can really treat pain alone.” He explains, “You don’t want to choose a certain type of doctor, necessarily, but a good doctor in a good practice.”

“Pain practices should be multi-specialty, with a good reputation for using more than one technique and the ability to address more than one problem,” he advises. “A true multi-specialty pain management facility should have doctors from several different specialties.”

Unfortunately, “what is seen as multi-specialty practice now is a practice with many doctors with a core specialty—say neurosurgery or orthopedic surgery—plus a few satellite doctors,” from other fields. As Dr. Arbuck explains, “If you have one doctor or specialty that’s more important than the others,” the therapy that specialty favors will be emphasized, and “other treatments may be ignored.” This model can be problematic because, as he describes: “One pain patient may need more interventions, while another might need a more psychological approach.” And because pain patients also benefit from multiple therapies, they “need to have access to doctors who can refer them to other specialists as well as work with them.”

Another advantage of a multi-specialty pain practice or clinic is that it facilitates regular multi-specialty case conferences, in which all the doctors meet to discuss patient cases. “Without case conferences, specialties don’t communicate,” Dr. Arbuck points out. Think of it like a board meeting—the more that members with different backgrounds collaborate about an individual challenge, the more likely they are to solve that particular problem.

At a pain clinic, you might also meet with occupational therapists (OTs), physical therapists (PTs), certified physician’s assistants (PA-C), nurse practitioners (NPs), licensed acupuncturists (LAc), chiropractors (DC), and exercise physiologists. And because people living with pain often suffer from conditions such as anxiety, depression, and insomnia, staff may also include psychologists, who have a PhD or a PsyD, or psychotherapists. The latterare often social workers, with titles such as licensed clinical social worker (LCSW).

Dr. Arbuck views effective pain medicine as a spectrum of services, with psychological treatment on one end and interventional pain management on the other. In between, patients are able to obtain a combination of pharmacological and rehabilitative services from different doctors and other healthcare providers.

Since chronic pain conditions are often accompanied by comorbidities, or overlapping conditions, multiple treatment approaches may be needed for a patient to find relief. Image courtesy of the Indiana Polyclinic.

What Happens at a Pain Clinic?

At your first visit, you’ll likely be seen by a generalist—that is, an internal medicine practitioner (internist), a nurse practitioner, or a physician’s assistant who’s being supervised by a doctor. 

Initial appointments might include one or more of the following: a physical exam, interview about your medical history, pain assessment, and diagnostic tests or imaging (such as x-rays). In addition, “A good multi-specialty clinic will pay equal attention to medical, psychiatric, surgical, family, addiction, and social history. That’s the only way to assess patients thoroughly,” Dr. Arbuck explains.

At the Indiana Polyclinic, for example, patients have the opportunity to consult specialists from four main areas:

  1. General medical. This might be an internist, neurologist, family practitioner, or even a rheumatologist. This doctor typically has a wide knowledge of a broad medical specialty.

  2. Interventions. This doctor is likely to be from a field that where interventions are commonly used to treat pain, such as anesthesiology. These doctors are experts in physical structure—anatomy and neuroanatomy.

  3. Rehabilitation. This provider will be someone who specializes in the function of the body, such as a physical medicine and rehabilitation (PM&R) doctor, physical therapist, occupational therapist, or chiropractor.

  4. Psychology/psychiatry. Depending on the patient, he or she may also see a psychiatrist, psychologist, and/or psychotherapist.

The patient’s primary care physician may coordinate care.

What to Know Before Your First Appointment

Although some patients (and doctors) may think otherwise, “Pain management does not equal narcotic prescriptions,” says Dr. Arbuck. “Narcotics are just one tool out of many, and one tool cannot work at all times.” Moreover, he notes, “pain clinics are not just places for injections, nor is pain management just about psychology. The goal is to come to appointments, and follow through with rehabilitation programs. Pain management is a commitment. It’s an expense, and it requires time and discipline at home.”

Individuals attending pain clinics should be prepared for delays in getting insurance companies’ approval for recommended treatments, Dr. Arbuck points out. Treatment can be expensive and because of that, patients and doctor’s offices often need to fight for medications, appointments, and tests, but this challenge occurs outside of pain clinics as well.  

Patients should also be aware that anytime controlled substances (such as opioids) are involved in a treatment plan, the doctor is going to request drug screenings and Patient Agreement forms regarding rules to adhere to for safe dosing—both are recommended by federal agencies such as the FDA (see a sample Patient-Prescriber Opioid Agreement at https://www.fda.gov/media/114694/download).

At a typical pain clinic, an individual has access to doctors of different specialties, including physical therapists and psychologists. Image courtesy of the Indiana Polyclinic.

One Pain Warrior’s Experience at a Pain Clinic

After her primary care physician diagnosed her with chronic migraine 14 years ago, Wendy struggled to manage the pain that radiated from the corner of her right eye. “I didn’t just have pain in my head, it was in the neck, jaw, absolutely everywhere,” recalls the HR professional, who lives in the Indianapolis area.

Wendy began seeing a neurologist, who put her on high doses of the anti-seizure medications gabapentin and zonisamide for pain relief. Unfortunately, she says, “The pain got worse, and the side effects from the medication left me unable to function—I had memory loss, blurred vision, and muscle weakness, and my face was numb. I could not concentrate or think clearly.” Eventually, she was forced to leave her job.

Wendy’s neurologist gave her Botox injections, but these caused some hearing and vision loss. She also tried acupuncture and even had a pain relief device implanted in her lower back (it has since been removed). Finally, after 12 years of severe, chronic pain, Wendy was referred to the Indiana Polyclinic.

At her evaluation, Wendy was scheduled to see the clinic’s occupational therapist and pain psychologist. She also underwent various assessments, including an MRI, which her previous doctor had performed, as well as allergy and genetic testing. From the latter, “We learned that my system does not absorb medication properly and pain medications are not effective.”

Shortly thereafter, Wendy got some surprising news: “I found out I didn’t have chronic migraine, I had trigeminal neuralgia.” This disorder presents with symptoms of severe pain in the facial area, caused by the brain’s three-branched trigeminal nerve. 

The new diagnosis prompted a different treatment approach. Wendy started receiving nerve blocks from the clinic’s anesthesiologist. She gets six shots of lidocaine (a local anesthetic) and an anti-inflammatory to her forehead and cheeks. “It’s five minutes of excruciating pain for four months of relief,” Wendy shares.

She also took the opportunity to work with the clinic’s pain psychologist twice a month, and the occupational therapist once a month. “They helped me learn how to live differently,” Wendy says. "From the way I exercise to the way I clean my bathroom, it was a total lifestyle change.”

The psychologist also helped Wendy to “not let the ‘What ifs’ prevent me from doing things.” Previously, “I was afraid to go anywhere and do anything. I hadn’t seen a movie in a theater in over five years because I’d think, ‘What if I get a headache?’” Thanks to her sessions with the psychologist, Wendy is once again able to enjoy outings and activities.

Occupational therapy helped Wendy identify her pain triggers, from bad weather to leaning over the bathtub, and to adjust her behavior accordingly. “Now, I take breaks when I’m mowing the lawn, and I don’t stay out too long in the heat,” she says. “It’s about learning how to get in front of the pain—being aware of how I’m doing things, and how it might affect my pain.”

Within six months of her first clinic appointment, Wendy was able to return to work. And now, “Every month I get healthier, I get stronger,” she says. She continues to see the anesthesiologist three times a year, and the OT and pain psychologist twice a year, or as needed. She also takes a daily dose of Seroquel [quetiapine, an antipsychotic], and the occasional Imitrex [sumatriptan, a triptan] for pain. Thanks to this program, she says, “I can participate in my life, in my child’s life, and in my husband’s life.”

Wendy is a big fan of the model she encountered at the Indiana Polyclinic. “It is life-changing, they treat you from every angle.” Then, she echoes Dr. Arbuck: “But you do have to work it. It doesn’t just happen.”

Updated on: 06/12/19
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