Seems like a simple question, doesn’t it? Actually, I do get asked about what a pain doctor does with some regularity in my personal life outside of the office. A little more commonly, I’ll get asked some derivative of that question, such as “what types of pain or what types of conditions do you treat?” However, I was surprised recently during a phone call with a close friend from medical school, who also happens to be a neurologist, when he asked me, “What patients should I be sending for pain management?” While I was growing up and even when I was in medical school, I had never really heard about pain doctors. So, I know that pain medicine has only partially entered the public consciousness at this point. But I was caught off guard when I realized that specialization in chronic pain management has only partially entered the medical community’s awareness as well!
According to WebMD.com, “pain specialists, or pain medicine doctors, are experts at diagnosing the cause of pain and then treating it.” While that’s basically correct, that definition is a little nebulous. Let’s take a step back and let’s first recognize that pain at it’s most basic level is divided into acute pain and chronic pain. Any acute pain that is unlikely to resolve or pain that lasts longer than the usual healing time is defined as chronic pain (1). Essentially, acute pain that a person experiences for longer than 3 months becomes considered chronic pain. In the outpatient setting, most acute pain conditions are initially diagnosed and/or managed by your primary care physician or surgeon. Poorly controlled pain in the hospital setting (after a surgery for example) may lead to a pain consultation, but these evaluations are generally performed by anesthesiologists with expertise in acute pain. So here’s how I would take the WebMD definition a step further. Pain medicine doctors are experts in diagnosing and treating acute and chronic pain who specialize in the evaluation and management of patients with painful conditions, usually chronic in nature, that are beyond the scope of routine management by other physicians. Most of us have a primary specialization in anesthesiology, neurology, and physical medicine and rehabilitation and the majority, such as myself, have also gone through extra training (called a fellowship) and hold subspecialty certification in pain medicine.
What do I mean by “beyond the scope of routine management by other physicians?” Basically, most physicians will try some routine treatment options before referring their patients to pain management. They may refer the patient to physical therapy. They may prescribe a trial of anti-inflammatory medication or a pack of oral steroids. Some physicians, particularly orthopedic surgeons, will perform basic injections, such as trigger point injections or joint injections. For the majority of patients, these interventions will successfully relieve their pain (either that or the natural healing process will take care of the problem on it’s own). When the routine management options are unsuccessful, this is typically the ideal time for a pain management consultation. Primary care doctors have many other problems to deal with (high blood pressure, heart disease, infections, and the list goes on!), surgeons need to operate, or perhaps it’s simply time to send someone with a painful condition that is quickly becoming chronic to a specialist that can focus more specifically on the problem and who may be able to offer a different skill set. For example, the patient with a back injury, shooting pain down the leg (sciatica), and an MRI showing a bulging disc who isn’t getting any better after a round of oral steroids and a course of physical therapy, maybe it’s time to consider an epidural steroid injection or some other medication options. The pain doctor is the perfect person to take over care to perform that injection or identify other medication options.
There’s also one more elephant in the room. Pain doctors are often identified, and rightfully so, as the doctors that prescribe opioids (narcotics). This is especially true in states, such as where I practice in Ohio and Kentucky, where the law changes have made it very difficult for general practitioners and surgeons to prescribe anything other than short term courses of low dose opioids. The topic of prescriptive privileges for opioids is an entire post (at least) in and of itself, so I mainly want to emphasize the following. Pain doctors are the most well-equipped to manage opioids with our training background and the structure of our clinics (routine drug screens, monitoring of pharmacy reports, pill counts, etc.), but we also have many other tools in our toolbox. With the growing problem of prescription opioid abuse, chronic pain physicians really should be the captains of the opioid ship and should lead the way with responsible opioid prescribing habits. But a good pain specialist will also offer other options that are appropriate for the painful condition that will supplement or potentially replace opioid therapy. These options could include non-opioid medications (i.e. anti-inflammatories, muscle relaxants, neuropathic agents, etc.), indicated interventional procedures, and non-medication/non-injection options, such as TENS units or referrals for physical therapy, massage therapy, acupuncture, and so on.
So what is a pain doctor? At this point, I hope you have a more clear picture. We’re a group of specialists that focus primarily on the treatment of chronic pain caused by a variety of medical conditions. We generally work in conjunction with referring doctors (although I do have many patients who schedule with me directly bypassing the referral process) and we use our expertise to bring new options to treatment plans with the goal of alleviating pain or making it much more tolerable so that people can regain as much function and enjoyment from life as possible. If you already take opioid medications, then chances are that you may have already seen a pain doctor (or maybe a few!). If you have a persistent pain that is not improving as quickly as anticipated, maybe it’s time to think about going to see a pain doctor. Now when your family doctor wants to send you to pain management, instead of saying, “What is a pain doctor,” you can say, “That’s what I was thinking. Who’s the best pain doc you know?”