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7 Articles in Volume 5, Issue #1
Diagnosing and Managing Interstitial Cystitis
Intractable Pain Centers’ Treatment Approach
Musculo-Skeletal Diagnostic Ultrasound Imaging
Pain Management Pitfalls
Selection Criteria for Intrathecal Opioid Therapy: A Re-examination of the "Science"
‘High Dosage’ Opioid Management
‘Opiophobia’ Past and Present

Intractable Pain Centers’ Treatment Approach

Correctly identifying and certifying intractable pain patients legitimizes palliative treatments that may be required to alleviate the debilitating pain and suffering of these individuals.

[Editor’s Note: Our campaign to promote intractable pain centers throughout The United States continues with this being the third in the series. It is time to share with you one of the inputs received from your colleagues. We selected a dissertation from Dr. Thomas Purtzer to be a guest editorial for this issue. Dr. Purtzer is a well-known and frequently published pain physician. He is the Director of Medical Operations for the Back 2 Backs Pain Management Centers. The words that follow and the approach he espouses are his without any attempt on our part to create conformity with what has previously been discussed. He introduces a term that we have never used or seen before: Intractable Pain Disorder (IPD). We are gratified by the knowledge that a prominent pain management specialist is an ally in our campaign.]

Intractable pain disorder (IPD) is a pain state in which the cause of the pain cannot be removed or otherwise treated. IPD presents incurable pain that causes the patient to suffer to a degree that is intolerable and significantly decreases their functional state and enjoyment of life. Yet there are huge numbers of such patients who are not being evaluated and effectively treated. It has been estimated that up to 3% of the population will eventually suffer from intractable pain. That estimate may be conservative over time as the U.S. population ages but, even if accurate, represents a large number of patients. At present, primary care physicians are treating some of these patients yet the vast majority are not being evaluated nor adequately treated for many reasons that have been well chronicled in the pain management literature. Under-treatment of pain is very common and yet is not due to any malfeasance by the primary care provider.

It is always problematic for a physician when he is considering whether or not to treat a patient with medications and, particularly so, when it may be for the rest of the patient’s life. The exact cause of a patient’s pain will oftentimes not be determined definitively. It has been estimated that up to 70% of patients will not have an exact diagnosis as to the cause of their chronic and intractable pain. This fact — combined with the subjective nature of the pain complaint — oftentimes make it very difficult for the primary care provider to provide effective pain management. The key issues are determining whom to treat for pain and how. Specialized intractable pain centers can evaluate and identify those patients that have an intractable pain disorder (IPD) and provide them with certification of their diagnosis so as to expedite and legitimize their palliative treatment by either their primary care provider or an IP center.

Evaluation and Certification of IPD

The complexities associated with an individual’s pain state needs to be fully evaluated and every effort expended to relieve the pain with curative means prior to palliative care. Associated biological, psychological, cultural, and social factors contributing to their suffering need to be identified.

Evaluation for certification of IPD includes:

  • comprehensive pain related history review of systems
  • past medical history; assessment of pain behavior
  • assessment of the pain level and its tolerability; assessment of the patients’ mood, anxiety and stress
  • physical examination
  • review of previous treatments with results
  • review of previous diagnostic testing
  • review of previous specialist evaluations
  • evaluation for development of Chronic Pain Syndrome (CPS) utilizing the Chronic Pain Inventory (CPI)
  • and neuropsychological screening test (MBMD), if indicated.

This evaluation procedure results in a five-axis diagnosis for the patient as follows:
Axis 1 — determines if the patient has developed CPS and to what extent it is impacting their life.
Axis 2 — assesses a putative causation of the patients’ intractable pain and its rationale.
Axis 3 — assesses any neuropsychological diagnoses that are involved in the patients’ intractable pain.
Axis 4 — assesses any medical conditions that the patient has that may impact their pain or its treatment
Axis 5 — assesses the functional status of the patient.

Certification of the patient as suffering from intractable pain disorder will be accomplished by providing the patient with a typed summary of their entire workup, diagnoses, and treatment recommendations that can be used to summarize the IP center’s opinion to other health care providers or legal authorities. This certification should help to expedite treatment and legitimize the patient’s complaints in a coherent fashion.

Special Considerations

Legitimate concerns exist about addiction and drug diversion when dealing with controlled substances. It is crucial for an IP center to do an initial screening for, and continuous monitoring of, potential abusive behavior prior to certifying that a patient has IPD. Referral for evaluation by an addictionologist may be required to assess or clarify the role that addiction issues may be playing in the patient’s need for medical treatment.

Even when there is no doubt that the patient is suffering from IPD, there is often reluctance on the physician’s part to treat the patient’s complaints of intractable and debilitating pain because of many underlying concerns including, but not limited to:

  • uncertainty as to whether a curable diagnosis has been missed
  • causing addiction by prescribing
  • becoming involved in the diversion of controlled substances
  • possible adverse complications
  • regulatory scrutiny
  • peer disapproval
  • difficulties in dealing with patient’s requesting these medications
  • difficulties in dealing with the patient’s associated depression, anxiety, and failed coping techniques
  • difficulties in dealing with fractured family relationships
  • inadequate pain control
  • struggles over which medications to use and at what dosage limits
  • institution and enforcement of drug contracts
  • referral to addict specialist
  • referral to mental health workers
  • referral to advanced tertiary pain management centers
  • excessive utilization of health care evaluation and treatment facilities
  • inappropriate prescribing
  • lack of belief in medications to control a patient’s symptoms

It is important to note that there are rarely definite treatment goals when reluctant prescribing of medications is undertaken. In such situations, both the patient and the physician are unclear as to what they are treating and what the endpoints of treatment are.

IP Center Specialized Care

Once it has been established that a patient has IPD, a clear treatment plan should be established. By definition, intractable pain is not curable and so management of the pain to a tolerable degree, along with improvement in functional ability, should be the treatment goal. Periodic monitoring and enhancement of such goal-oriented treatments is ideally suited to a specialized intractable pain center.

Specialized IP centers address any further or ongoing evaluations that may be needed to complete a patient’s workup. For example: whether or not long-term pain management with opioids is indicated and what other type of treatment is indicated to improve functionality. In the event long-term opioid usage is indicated, the need for a use of an informed consent contract for long-term use of controlled substances will be discussed with the patient and executed before treatment begins. Patient education and functional ability recommendations will be outlined in any treatment plan and ongoing education will be advised and expedited with the patient on an ongoing basis.

Ancillary treatments for depression, anxiety, and sleep disturbances will be included since improvement in these areas oftentimes enhances pain control. Educating patients in effective coping techniques are also part of their pain treatment program since stress reduction, relaxation, and meditation have beneficial effects on the patient’s ability to maintain pain control and improve functionality.


While the author has seen an increase in physicians willing to prescribe pain medications, concern is rising about the inadequate prescribing practices of some of these primary care providers when dealing with the complex needs of pain patients. Many patients are not treated appropriately, nor given informed consent, nor monitored for diversion, nor treated for their associated psychological difficulties, nor trained to control their pain with measures other than opiates. These shortcomings typically are the result of limited time, education, or interest that a busy primary care physician can devote to managing these complex patients.

Specialized intractable pain centers can offer the primary care provider a crucial resource in evaluating pain patients with a complete workup, initiating and managing long-term pain management, and maintaining an ongoing monitoring and verification protocol to ensure adequate palliative care and functional improvement of each patient while satisfying the legal requirements under the controlled substances law. While the author has implanted over 50 spinal cord stimulators and over 100 intrathecal morphine delivery systems, he believes that the future of pain management lies in the development of focused clinics that deal exclusively with pain management in a widely available and cost effective manner and act in concert as a virtual team with the primary care providers. Structured “virtual team” arrangements between the primary care physician and a specialized intractable pain center — having clear lines of authority, allocated responsibility, and appropriate documentation — can assure optimum pain patient treatment, while assuring the financial viability of intractable pain centers, and a reduction in liability insurance issues.

Last updated on: May 16, 2011
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