On Your Health

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What Does a Pain Management Doctor Do?

Dr. Atul Walia fights an uphill battle every day regarding the myths surrounding the role of pain management doctors. For starters, many patients don’t know who or what a pain specialist does. The confusion is real.

Dr. Walia, medical director of the INTEGRIS Pain Management Clinic, regularly receives referrals for patients with pain problems who talk about not wanting to see a doctor who pushes pain pills. Instead, he must explain he can provide other procedures to help reduce pain.

“I can't tell you how many times people automatically think that's what I do for a living and that's all we do,” he says. “That's the biggest myth I fight every single day.”

To help you better understand what a pain management doctor does and how he or she can help you, we asked Dr. Walia, who is a board certified anesthesiologist with fellowship training in pain management, about several common topics patients should know.

Types of pain management doctors

Many years ago, anesthesiologists handled everything from prescription pain management to pain management procedures. Now, the anesthesiology and pain management specialties are separate, and it’s important to know the differences when selecting a provider.

“Pain management, historically, has been offered via the field of anesthesiology. This started many years ago because anesthesiologists were well versed in medications, particularly local anesthetics, pain medicine and also in different types of procedures for nerves, such as nerve blocks and different types of spine techniques (epidurals),” Dr. Walia says. “That's where the history of pain management came from.”

Currently, there are two types of pain management doctors: those who specialize in interventional procedures and those who specialize in medical pain management.

Interventional pain management

This subset of physicians is knowledgeable in higher techniques and advanced pain management procedures, such as nerve blocks, spine injections and spine implants. Most interventional pain management specialists complete a five-year anesthesiology residency followed by a one-year pain management fellowship.

There are also a group of physicians called PMNRs (physiatry) who can go into a pain management fellowship via their specialty. Neurologists can also specialize in pain management.

Medical pain management

As the name suggests, these doctors work with patients who have chronic ailments that require opioids or other long-term medications. A medical pain management specialist can be anyone from a family medicine doctor to an internal medicine doctor or psychiatrist. For example, a patient on methadone for chronic pain would see a medical pain management specialist, not an interventional pain management doctor.

A medical pain management specialist is especially useful in navigating the many new regulations and laws regarding pain medications (more on that later). They’ll help ensure you’re taking the right dose for the right amount of time to help offset the risk of dependence or addiction.

When to see a pain specialist

While you don’t always need a referral to see a pain specialist, most of the time these visits come after seeing your primary care physician (PCP) and another specialist, such as a neurosurgeon or orthopedic surgeon.

For example, your PCP may order X-rays, prescribe anti-inflammatory medications or send you to physical therapy. In the event those treatments don’t work, they’ll send you to a surgeon for further evaluation. If the surgeon deems you a non-surgical candidate, they’ll refer you to a pain specialist. In some cases, a PCP may have managed an ailment for years with conservative treatment, then refers you directly to a pain specialist when the situation turns chronic.

While pain specialists treat a litany of ailments, spine disorders, including herniated discs in the lumbar (back) or cervical (neck) spine, are the most common issues. You may also see a pain specialist after a hernia repair for a nerve block in your groin, or a neurologist may refer you to a pain specialist to receive nerve blocks for chronic headaches.

Whatever your ailment, Dr. Walia says a pain specialist will work with your other physicians to provide you with a multidisciplinary plan, whether it's physical therapy, appropriate medications, injection therapy or surgery.

“A multidisciplinary approach is always my first approach. We do offer multi-modal medicine, whether it's nerve agents, anti-inflammatory agents or muscle relaxants,” he says. “If a patient ever becomes chronic where they're requiring many prescriptions, they need to see a medical pain specialist, but the initial plan when you see a doctor like me, I’ll tell you the five things we need to do and here's where we're going to start. If the plan changes or grows in a different direction, then we'll accept that if we need to.”

What to expect during your first visit

If you think your pain has become unmanageable and you need to see a pain specialist, Dr. Walia suggests researching names before asking your PCP for input. Tell your PCP your concerns and ask them if a pain specialist is appropriate. They can confirm if you’re headed in the right direction.

“Remember, there are different types of us now, not just one all-encompassing doctor. We're all trained differently,” Dr. Walia says. “Nowadays, there's a benefit to making sure your pain management physician is fellowship-trained because there's so much new technology, so many new advancements that only fellowship-trained physicians offer.”

Once you find a doctor, preparing for your visit will make for as smooth of a transition as possible. For starters, keep a pain journal to track your symptoms. Note where the pain is, what it feels like, the frequency of pain, if certain positions make it worse or if certain positions help the symptoms.

Records are important, too. Bring a hard copy of any imaging you’ve had in case the office hasn’t received it yet by your first appointment. Also write down any medications, either prescription or over the counter, that you’re taking.

At your appointment, tell your doctor if you have specific goals. For example, if your back pain bothers you daily and you can’t play golf three times a week anymore, mention that. There may be a remedy to bring you some relief so you can still enjoy certain hobbies. Lastly, bring a family member with you (if your provider allows that). First appointments can be overwhelming. A family member can help reduce any concerns, ask questions for you and help you understand your treatments options.

How opioids have changed pain management

The way in which pain management specialists treat patients has changed since the 1990s, mainly due to the opioid epidemic and a rise in addiction and death rates. In the United States alone, 47,600 people died from opioid overdoses in 2018, according to the U.S. Department of Health and Human Services.

Dr. Walia recalls when doctors learned that pain was the fifth vital sign and how they needed to work on controlling pain for patients. Why? Drug company lobbyists marketed how pain was undertreated in society and how it was safe to use as much pain medicine as doctors wanted to give patients because they claimed there was little chance of addiction, tolerance or dependence.

“Then in the early 2000s, we realized we were having an addiction epidemic with overdoses,” Dr. Walia says. “Since then, the pendulum has shifted now to this multidisciplinary approach where we're not saying we won't prescribe pain medicine for patients, but we're saying we need to identify a multidisciplinary approach to address acute pain issues, whether that means adding physical therapy to the mix or adding non-opioids or adjunct medicines to the mix.”

Oklahoma opioid laws and regulations

Nowadays, physicians have a broader and perhaps a stricter view on opioids, but Dr. Walia stresses doctors aren’t outright saying no to opioids. They have a time and place depending on each patient's condition. Plus, the laws have helped.

Since 2018, Oklahoma has passed three bills to crack down on opioid prescriptions. Senate Bill 1446 and Senate Bill 848 limited first-time opioid prescriptions for acute pain to seven days. Your doctor can prescribe a second seven-day prescription if needed. Here is a best practice opioid guide from the Oklahoma Hospital Association to better under each bill.

For the third prescription, you have to sign a patient-provider agreement — also required if you need more than three months of pain management; combine benzodiazepines and opioids together; if you’re prescribed more than 100 mg morphine milligram equivalents (MME); if you’re pregnant; or if you’re the parent of a minor — and your physician must make sure there is a multidisciplinary plan in place for the pain that's requiring another prescription.

Physicians, along with other medical personnel such as physicians' assistants, nurses, optometrists and dentists, must take continuing education courses annually. They’re also required to discuss the benefits and risks of opioids. In addition, there's regulations on what doctors need to write on the prescription (acute or chronic). House Bill 2931 made it a requirement to only electronically prescribe scheduled drugs (Class II-V). This law prevents prescription drug forgery.

“Patients are a little more understanding when we turn around and say, ‘Let's try this medicine, but just for the next seven days because, No. 1, it's the law, but it also makes sense because we can see if we're heading in the right direction,’” Dr. Walia says.

The future of pain management

New product innovations continue to grow the field of pain management. Dr. Walia highlights two new treatments that have helped patients with chronic spine problems.

First, neurostimulation, which is a device that sends electrical activity into the dorsal column of the spinal cord, can help reduce back pain and nerve pain down your leg. Neurostimulation can help relieve continued pain or weakness after a herniated disc or major spine surgery.

“You implant this device in the spine, and it changes the pathway the brain sends messages to the spine, thus improving chronic pain,” Dr. Walia says. “It's been a game-changer for patients, especially our spine patients who have had big surgeries and didn't do well with them.”

The development of the interspinous spacer has also helped patients who suffer from spinal stenosis, which is a severe narrowing of the spine. This metal spacer is a small implant that goes between your vertebrae to open the spinal canal and relieve pressure.

“For many, many years we didn't have options for those patients. Injection therapy was always an option, but the success rates were very poor — less than 50% success rates,” Dr. Walia says.

Moving forward, Dr. Walia has his eyes set on regenerative medicine. The therapeutic options mentioned above help reduce symptoms. The goal with regenerative medicine is to repair and be proactive against disc diseases and degenerative spine changes.

If you think one of these procedures could help with your chronic pain or if you want to learn more about this field, visit the INTEGRIS pain management page. You can also contact INTEGRIS here for more information or look up an INTEGRIS physician near you to set up an appointment.