Chronic Pain Treatment: An Algorithm

A chronic pain patient may see many doctors, from general practitioner to pain specialist. But what comes between those visits? What’s the process?

Usually:

• The patient is managed conservatively by the primary care doctor or practitioner, which may entail certain medication therapies or physical therapy for pain
• If it reaches the point where the patient is not improving and quality of life hasn’t changed, that’s when primary care doctors may refer to a pain specialist such as myself

And once the patient comes to see me:

• I do a physical examination and conduct a history
• I figure out where their primary pain is and what the next best course is, say, interventionally or medically
• PCPs usually try things like acetaminophen or NSAIDs, or advanced therapies like gabapentin or pregabalin
• My goal is to partner with the patient to try to determine what s/he feels comfortable trying first. It might not be an intervention; it might be another medical therapy; and we embark upon that
• We may try a combination of medications—giving to the patient for perhaps 6 weeks to determine efficacy; if it’s just partially effective then trying an intervention, a nerve block procedure, for example, for additional pain relief

Referral timeframe?

• Probably, ballpark, there is ~3 months before a referral is made to a pain specialist
• It’s difficult: some medications require an adequate trial, which could be several weeks
• But 3 months is a figure that PCPs and clinicians usually give a patient with, say, physical therapy or even trying integrated techniques like acupuncture or medication