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5 Articles in Volume 4, Issue #1
Complications of Uncontrolled, Persistent Pain
Improving Postoperative Pain Outcomes
Peripheral Nerve Catheters for Acute Pain Control
The ABC's of Pain Clinic Referrals
Treatment-resistant Migraines

The ABC's of Pain Clinic Referrals

Some basic, common-sense criteria for referring a patient to a pain treatment clinic.

“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:

  1. Interventional Procedures
  2. Rehabilitation Management and
  3. Training
  4. Medication Management
  5. 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:

  1. The question of a pain generator.
  2. If the physician feels a damaged nerve, known as neuropathy pain, or other structure may be playing a primary role in generating the pain, or simply wants to answer the question of whether this is the case, referral to an interventional specialist may be of enormous assistance in further diagnosing the problem.4
  3. Interventional practitioners can provide enormous assistance, not only in treating pain but in facilitating, where possible, a more accurate diagnosis.
  4. The question of function.
  5. When the patient has experienced a major loss in function, referral to a program of pain rehabilitation is in order. It is often the case that longstanding pain sets up longstanding changes in behavior—physically, emotionally and cognitively. This set of problems is best dealt with in a team approach with multiple practitioners connecting with the patient addressing different needs but working in a coordinated fashion.
  6. The question is pain, and only that.
  7. The primary physician or specialist may have the perception that all the patient needs is a reduction in pain and the pain is already well identified. The physician has known the patient for some time and recognizes or believes that with adequate reduction in pain, the patient may easily improve all over. He or she may simply not be comfortable with managing the medication regimen which brings the patient to this level. In this case, referral to a medical management specialist or to an interventional or rehabilitative center with a request for medical management is appropriate.
  8. In any event, at the first referral the primary physician should trust his/her judgment as to what the patient needs since they know the patient best.
  9. The question is comfort.
  10. Palliative care is a term which has arisen as dealing with end-of-life comfort management. Hospice programs have arisen as the carriers of the banner. Obviously, patients near the end of life have particular issues, as do their families. Another group of patients may be more accurately described under this rubric however.
Typical strategies to address a patient’s pain-related issues
1. The diagnosis is in question and a specific nerve or structure is suspected. Interventional specialist
2. The patient has significant functional decline with a hope of improved function. Rehabilitation approach
3. The patient is likely to improve with medications but I'm not comfortable with the doses needed. Medication management
4. The patient and I are primarily interested in improved comfort Palliative care
5. I already have a great pain doctor (of any type) who serves my patients well. Stay with who you know
Patient presentations suggestive of need for pain clinic referral
  1. chronic pain accompanied by physiologic changes in blood pressure, pulse, hormones (a.m. cortisol, testosterone)
  2. chronic pain accompanied by functional loss
  3. c) chronic pain accompanied by psychological dysfunction
  4. chronic pain accompanied by neuromusculoskeletal changes/postural or gait changes
  5. chronic pain accompanied by
  6. medication management

A number of pain practitioners have come to perceive that some patients without identified terminal diseases have pain so severe to the pain itself is affecting the patient’s physiologically.5 This is occurring in ways which could likely impact longevity. Increased function is not the primary focus here as it is an unlikely goal. Rather comfort — as with more identified terminal patients — is the goal. Such patients may benefit from a palliative approach if such is available to them.

The key point is to be aware that pain of all types, including incurable, intractable pain can now be helped, and the best help is to simultaneously retain the pain patient in both primary medical and pain treatment.


By identifying patients in need of more specific pain treatment, a physician serves the patient’s needs as well as those of his/her practice.2,3 The key point is to be aware that pain of all types, including incurable, intractable pain can now be helped, and the best help is to simultaneously retain the pain patient in both primary medical and pain treatment. Table 2 presents some of the criteria related to patient presentation that strongly indicates a need for referral to a pain clinic.

Last updated on: December 28, 2011
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