| One-Minute Clinician

When Pain Patients Fail Standard Treatments

In the last two years, states regulators have essentially codified what amounts to standard treatment for chronic pain. Now we’ve always had the World Health Organization three-step ladder and a lot of guidelines, but states have drilled down and said that opioid dosage of between 60 and 120 mg of morphine equivalence is standard treatment. So what the state is fundamentally doing is saying primary care doctors, nurse practitioners, PharmDs can go up to this level. If you’ve got to go above that level, that is the specialist purview. Now this isn’t all that strange because in cardiology, endocrinology, rheumatology, you have certain conditions that a primary care doctor can do. In terms of the proportion of pain patients who fail at these treatment levels, we don’t really know the number, but we know it’s uncommon. The vast majority of pain patients in the country can be managed within the standards. That’s good because we have a lot of people in the system who are nurse practitioners, physical therapists, chiropractors, podiatrists, a lot of allied health people, and they’re going to work on those cases. It’s the other 5 or 10 percent, whatever it is, who are going to have to be taken care of by people like myself. Many state guidelines ask the primary care practitioner, to consult with the pain specialist and find out what his or her opinion would be and then implement at that at the primary care level. That has to be done because there aren’t enough of us pain specialists to take care of these things.

Within the last two or three years, for difficult, non-standard cases, we’ve begun doing what other branches of medicine do, by underpinning the treatment of these people with laboratory testing. Most people don’t know how advanced this has become. The best example is hormone profiles. Inflammatory markers of the nervous system itself can be identified. We have something new called pharmacogenetic testing. This amounts to the ability of the liver and the intestine to metabolize some drugs but not others. People with severe genetic defects are going to have to perhaps take a higher dose of drugs and receive special care. Serum testing of opioid drugs is very common now. And there are surprisingly many people who have abdominal surgeries, have autoimmune diseases or have head trauma that interferes with the gastrointestinal tract and so they can’t take oral medications. These people are going to need to be the purview of the specialists because they’re going to need injectable medications or non-oral formulations of some kind. So when you put it all together, the pain specialist needs to underpin the treatment of these difficult cases with laboratory testing. It is the laboratory testing that tells you which road to go down relative to treatment. That’s the way cardiac problems are taken care of, or diabetes, arthritis, asthma--this is not a new concept. In fact, this is quite good because it is bringing pain management into hardcore medical systems, as it should be. So I think patients are going to be in a lot better shape. I think it’s great for society.

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