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14 Articles in Volume 19, Issue #5
Agonism and Antagonism of the Muscles of the Shoulder Joint: An SEMG Approach
Analgesics of the Future: The Potential of IV Formulations for Post-Op Treatment of Pain
Blood Biomarkers Show Promise for Precision Pain Management
Can I Call Myself a “Pain Specialist?”
Cases in Urine Drug Monitoring Interpretation: How to Stay in Control (Part 2)
Fear-Avoidance and Chronic Pain: Helping Patients Stuck in the Mouse Trap
How to Avoid Patient Alienation When Discussing Stress
Managing Phantom Limb Pain with Medication
Nerve Blocks Lead to Improved Quality of Life
Sacroiliac Joint Dysfunction: New Methods in Evaluation and Management
SCS Therapy in a Patient with Advanced Bilateral Kienbocks
Thoracic Epidural Abscess with Cord Compression Following a High-Frequency SCS Trial
What is the evidence to support clonidine as an adjuvant analgesic?
What’s In A Name? In This Case, That Which We Call Addiction Is Not Dependence

Can I Call Myself a “Pain Specialist?”

Who defines the role of pain specialists? Do you qualify as one, and do the courts agree? Inside the legal requirements.
Pages 64-66

In April 2019, in the case of US v. Littleford, a Colorado physician was sentenced to 87 months in prison for overprescribing opioids that ultimately resulted in the deaths of at least two patients.1 In just one day in 2012, the physician wrote one single patient prescriptions for 840 tablets of 30-mg oxycodone; 120 tablets of 80-mg oxycodone; 360 tablets of Percocet (10 mg oxycodone/325 mg acetaminophen); 240 tablets of 100-mg morphine; 240 tablets of 2-mg Klonopin (clonazepam); and 240 tablets of 350-mg Soma (carisoprodol). The patient’s file contained no documentation of an exam, a diagnosis, or a treatment plan. To make matters worse, the patient had disclosed in his intake questionnaire that he had previously undergone opioid detoxification.

In most aspects, the facts of the Littleford case were egregious and have little to do with typical pain management practitioners. Upon closer reading, however, the case does highlight one major issue that should concern everyone: who qualifies as a pain management specialist?

The Department of Justice (DOJ), in a press release regarding the case, stated that Littleford “…held himself out as a practitioner in the field of ‘pain management,’ although he did not have any certification in that field and had not completed a medical residency, which would have been directly applicable to the field of pain management.”2 While that may sound like an obvious red flag to an outsider to the field of pain management, those of us with a deeper understanding may feel some unease at the DOJ’s statement.

Who qualifies as a "pain specialist?" (Source: 123RF)

Pain Specialists are in Short Supply

Unlike other medical specialties, such as pediatrics or cardiology, and despite what the DOJ seemingly implied, there are no independent residency training programs for the specialty of pain medicine or pain management.3 The medical residency referred to by the DOJ simply does not exist. Board certification in Pain Medicine is available, but a physician must first complete a residency training program in an entirely different specialty, such as anesthesiology, neurology, neurosurgery, psychiatry, or physical medicine and rehabilitation. Then, prior to obtaining board certification, the physician must either: (1) complete a one-year fellowship in pain medicine; or (2) provide proof of substantial training in pain medicine related-topics, and actively practice comprehensive pain medicine for a significant amount of time. This onerous path to pain specialization (in addition to the increasing scrutiny, and resulting fear, that pain practitioners face4,5) has resulted in a severe shortage of pain specialists, with nearly 30,000 Americans living with chronic pain for every one board-certified pain care physician.6

With so few board-certified pain specialists, and so many people living with chronic pain, is board certification really the only way to qualify as a pain specialist? The answer will depend upon the authority that one asks.

State Requirements Matter

If one practices in a state that has adopted laws or rules that govern pain management clinics, the answer may be found within those policies. Georgia, for example, does require board certification, as the state requires all physicians who practice in a pain management clinic to have: 20 hours of pain-related continuing education in the preceding two years; and evidence of current certification or eligibility for certification in pain management or palliative medicine by the American Board of Medical Specialties or the American Osteopathic Association, the American Board of Pain Medicine, and the American Board of Interventional Pain Physicians.Ohio, on the other hand, takes a much more lenient approach, requiring only the physician owner of a pain management clinic (just the owner—not all physicians practicing in the clinic) to hold a subspecialty certification in pain medicine or hospice and palliative medicine.8 Texas requires no specialty or subspecialty certification at all, requiring only that each practitioner working within a pain management clinic obtain 10 credits of pain-related continuing education each year.9 Most states have no policies relevant to pain management clinics or specialists.

With no federal guidance on the matter, and with only a handful of states having adopted relevant policies, there is no clear answer as to who qualifies as a pain specialist throughout the majority of the country.

Policies Increasingly Recommend or Require “Pain Specialist” Involvement

While very few states have adopted policies specific to pain management clinics and specialists, many policies at both the state and federal levels recommend consulting with, or referring a patient to, a pain management specialist at various times during treatment. The CDC Guideline for Prescribing Opioids for Chronic Pain, for example, lists circumstances in which primary care providers (PCPs) should “…consider consulting a pain specialist as needed to assist with pain management,” but the guideline is silent regarding what would qualify a practitioner to call themselves a “pain specialist.”10 The states take a wide variety of approaches. Some, including Indiana11 and New Hampshire,12 require consideration of a consultation with a pain specialist for certain patients on high doses of opioids. Others, such as California,13 recommend a consultation with a pain specialist in specific circumstances. What all of the various state policies have in common, save for the very few with policies specific to pain management clinics, is that they fail to define who actually constitutes a specialist that would sufficiently fulfill the intent of the prescribing policies.

In Colorado, where the Littleford case took place, there are no statutes or regulations that specifically regulate pain management clinics or specialists. There is, however, an official recommendation that prescribers should consult with, or consider referral of the patient to, a pain management specialist prior to issuing high dosage “outlier” prescriptions for chronic, non-cancer pain.14 Found within the very same recommendations is a link to the Colorado Pain Society’s “Pain Management Provider Locator,"15 so it seems that the guideline’s authors realized that prescribers would need help in identifying pain specialists.

However, a quick perusal of this tool turned up only 75 total members in the entire state of Colorado. Of these, only 17 members indicated “Pain Medicine Specialist” or “Pain Management” as their specialty. Another 16 members of the Colorado Pain Society specialize in anesthesiology or interventional pain management (largely injections, not prescribing), and the rest represent a variety of disciplines including physician assistants, nurse practitioners, chiropractors, stem cell therapists, and even one office manager — a wide variety of disciplines that clearly do not qualify for board certification in pain management. Most of these practitioners are likely not the pain specialists that the guideline intended to target in terms of consultations regarding high doses of opioids, nor would they meet the “certification” or “residency” standards referred to by the DOJ.

Closing Pain Organizations Create an Unexpected Dilemma

While the Colorado Pain Society’s member directory may not be the ideal tool for identifying the types of pain specialists contemplated by the Colorado guideline, it is the tool that the guideline provides—so how else would prescribers find pain specialists if that society were to shut its doors?

In Arkansas, a physician managing a Chronic Pain Management Program must have completed and maintained at least one of the following: attendance at one meeting per year of a regional and national pain society; presentation of an abstract to a regional pain society; publication on a pain topic in a peer-reviewed journal; or membership in a pain society at a regional or national level.16 On its face, this requirement seems reasonable. However, since this regulation was initially adopted in 1996, the field has seen the closure of the American Pain Foundation in 2012,17 the closure of the Academy of Integrative Pain Management (formerly the American Academy of Pain Management) in early 2019,18 and now the impending closure of the American Pain Society.19 What happens to the status of a Chronic Pain Management Program in Arkansas if the managing physician was a member of AIPM or APS? Are their programs now in noncompliance? Given the very busy schedule of most practicing physicians, it is highly unlikely that most of them will have been published in a peer-reviewed journal within the past year, so what are they to do if they do not qualify for membership at another—still remaining—regional or national pain organization?

Practicing During Uncertain Times

With more than 20% of US adults living with chronic pain, and 8% of US adults living with high-impact chronic pain, specialists in the field of pain management are more needed than ever.20 The last thing that our nation needs is for qualified and experienced pain practitioners to exit the field due to fear and uncertainty, so what can be done?

As is so often the answer in pain management, it is all about knowing your state’s local pain and prescribing policies, using your best professional judgment, and consistently keeping detailed records. To avert government scrutiny, prescribers should pay attention to, and account for, their aggregate prescription history and general prescribing patterns.21 Further, they should document utilization of opioid treatment agreements and their local prescription monitoring program, maintain strong provider-patient relationships, and utilize urine drug testing when appropriate. Finally, prescribers should always document when they consider consulting with, or referring to, another qualified pain management specialist.

If a prescriber has a specific concern related to their status as a pain specialist, they should consider contacting their licensing board for guidance and seeking an experienced attorney’s advice regarding compliance with local statutes, rules, and caselaw.

See Dr. Albert Ray’s response to this column, including a proposal for the path forward.

Last updated on: October 7, 2019
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When Opioid Prescriptions Are Denied
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