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Finding An RSD Specialist
By Alfie C Burns, President - RSDSA-CA
Office personnel at the RSDSA-CA have identified the most
frequently asked question from an RSD patient being, "Do you
know of an ‘RSD Specialist’ in my area?" Understanding more
about the ‘pain management process’ may help patients in selecting
a physician or pain clinic and what you may experience if
you begin a pain management therapy program.
Whether you are insured by private insurance like a PPO, or
are in an HMO program or insured under a state program such
as Medi-Cal, the process of pain management may ultimately
lead to a ‘team approach’ for patient care.
Basically, a person can begin with a physician in almost any
field of medicine when they are first diagnosed with RSD.
Depending on the stage of the illness and other physical or
mental conditions that may be present will determine the next
steps in treatment. The patient may be referred to one type
of specialist for certain tests and medication therapy, and
then to another specialist for other treatments such as nerve
blocks to help confirm the RSD diagnosis.
Most likely, at some point a physician will assume a role
as the ‘primary care doctor’ in pain management therapy to
coordinate the procedures and medications in the patient’s
care. This doctor may be an anesthesiologist, a neurologist,
a rheumatologist, an internist, a neurosurgeon or orthopedic
surgeon, or a doctor practicing General Medicine. Also included
in a Pain Management Program may be a physical therapist and
a psychiatrist or psychologist. The primary care doctor will
determine what a patient needs and will consult with all of
the appropriate fields of medicine to ensure a thorough pain
program is established. This can get very confusing and frustrating
for the patient because it may seem like ‘no one knows what
to do or anything about RSD!’ The process of evaluating treatment
for RSD is not an easy task.
The severe chronic pain is a major focus for the patient,
but the physician must consider the overall health of the
patient and any secondary medical conditions that require
treatment. Chronic pain is understood to be a persistent pain
that frequently is not amenable to routine pain control methods.
It can develop when pain lasts longer than is expected for
a trauma or injury. Because there are many differences in
what is regarded as chronic pain, management strategies remain
flexible and related to specific cases. The American Pain
Society has published an article discussing ‘Adjuvant Agents
for Managing Chronic Pain’ 1 (Adjuvant agents are those that
assist or aid other medication) that states: “Pathophysiologic
classification of pain may assist in selecting appropriate
therapies and determining a prognosis for patients. 2 There
are four major categories into which chronic pain can be classified:
nociceptive, neuropathic, mixed, or unknown origin. Nociceptive
pain can be either visceral or somatic; it is derived from
stimulation of pain receptors. 3 Development of nociceptive
pain may be due to the inflammation, mechanical deformation,
ongoing injury, or destruction of tissue. Neuropathic pain
involves a pathophysiological process in either the peripheral
or central nervous system (CNS) or both. 4 Examples of neuropathic
pain include trigeminal neuralgia, postherpetic neuralgia,
poststroke central or thalamic pain and phantom limb pain.
Chronic pain can have mixed or unknown mechanisms or it can
be psychological in nature. 5 These types of pain are unpredictable
and difficult to treat.
Because many different neurotransmitters (e.g., substance
P, serotonin, prostaglandin, bradykinin, leukotrienes, histamine)
and receptors (e.g., opioid, serotonin, acetylcholine, dopamine,
norepinephrine ) are involved in pain, many potential targets
for drug therapy exist. The selection of an appropriate analgesic
medication can be difficult. The World Health Organization
(WHO) has developed a three-step approach for selecting analgesics
for the management of chronic pain. 6 Not all physicians use
the WHO three-step approach universally, and this approach
may not represent a routine procedure to be employed for all
chronic pain patients.
The first-line agents are acetaminophen and nonsteroidal anti-inflammatory
drugs. If pain relief does not occur with these agents, low-dose
opioid combinations such as acetaminophen with codeine (Tylenol
No 3®), acetaminophen and hydrocodone (Lortab®, Vicodin®)
and acetaminophen with oxycodone (Percocet®) can be used as
second-line agents. If the pain is still not controlled, stronger
opioids such as morphine, hydromorphone, and methadone can
be used. For patients who still do not achieve adequate pain
control, it may be necessary at this point to consider adjuvant
analgesic therapy. Adjuvant agents are not typically thought
of as having analgesic properties. However, they are helpful
in maximizing pain control and lowering the required dosage
of opioids and can be used in combination with the above therapies.”
If a physician does not have a conclusive diagnosis of what
is causing the chronic pain or it is unclear if it is nociceptive,
neuropathic or a mixed classification of chronic pain, it
may take a trial of several different medications to find
those that are helpful in treating each patient. Even if there
has been a diagnosis of RSD, it may still require trying different
medications in each patient’s case because not all people
with RSD respond the same to medication.
The APS article continues to say, “The largest body of literature
on adjuvant agents focuses on the use of antidepressants,
specifically tricyclic antidepressants (TCAs) and their role
in nociceptive and neuropathic pain. 7 TCAs such as amitriptyline
(Elavil®), desipramine (Norpramin®) doxepin (Sinequan®) imipramine
(Tofranil®) and nortriptyline (Pamelor®) have been studied
for their role in treating neuropathic pain. Amitriptyline
has also been shown to be beneficial in nociceptive pain,
especially somatic pain. Newer antidepressants such as selective
serotonin reuptake inhibitors (SSRIs) have also been studied
for their role in chronic pain management. Fluoxetine (Prozac®)
has been shown to be effective in reducing pain and improving
global wellness scores in patients with fibromyalgia, especially
when used in combination with amitriptyline. In evaluating
the use of SSRIs in diabetic neuropathy, paroxetine (Paxil®
) has been demonstrated to produce an improvement in patients’
pain.
Anticonvulsants have been beneficial in treating spontaneous
shooting pain that manifest from neural damage. Neuroleptic
drugs such as carbamazepine (Tegretol® ) and phenytoin (Dilantin®
) have shown improvement in pain intensity. A newer antiepileptic
agent, gabapentin (Neurontin®) has fewer side effects than
the older anticonvulsants and analysis demonstrated a response
rate of 50% in patients with polyneuropathy and trigeminal
neuralgia.
N-methyl-D-aspartate (NMDA) receptor antagonists are used
to manage neuropathic pain. Dextromethorphan and Ketamine
are two NMDA receptor antagonists currently available. A hypothesis
as to the difference in response (in a clinical study of Dextromethorphan
by Nelson et al ) is that NMDA receptor antagonists are particularly
beneficial in patients with ongoing peripheral neuron damage,
as seen in diabetic neuropathy, but not in patients with fixed
lesions, which are common in postherpetic neuralgia. Chronic
pain will remain an issue for many patients who have failed
traditional analgesic therapy administered in accordance with
treatment guidelines. Practitioners must not only recognize
chronic pain but also aggressively treat the condition. Whenever
possible, treatment should be proactive rather then reactive.
Adjuvant agents are not considered first-line therapy in pain
management. Instead, they optimize pain control and provide
relief to patients who suffer from intractable pain.
Management of chronic pain is a complex process requiring
appropriate medication management as well as treatment of
the whole person. A management strategy must be tailored to
individual patient needs and situation, and must be constantly
reviewed to ensure optimal patient outcome.’ In reviewing
the ‘three-step approach for selecting analgesics for pain
management’ that was established by the World Health Organization,
RSD patients may recognize many of the medications mentioned
in the article as those that they have been given in their
own pain management program.
So, rather then focusing on trying to find a doctor that is
an ‘RSD specialist’ ... the patient should actually be seeking
is a physician that has certification in Pain Medicine or
Pain Management - Anesthesiology. While many organizations,
clinics and institutes offer continued medical education units
(CME units) for ‘pain treatment courses’ or ‘pain related
lectures or seminars’, this is not to be confused with the
actual Certification achieved in Pain Medicine or Pain Management
– Anesthesiology.
The American Board of Pain Medicine (ABPM) was founded in
1991 as the American College of Pain Medicine. In 1994 the
name was changed to the American Board of Pain Medicine to
reflect the nomenclature of other medical specialty boards.
This not-for-profit corporation operates as an autonomous
entity, independent of any other association, society, or
academy. “Pain Medicine has emerged as a separate and distinguishable
specialty that is characterized by a distinct body of knowledge
and a well-defined scope of practice, which is based on an
infrastructure of scientific research and education. Competence
in the practice of Pain Medicine requires advanced training,
experience, and knowledge.”
After an examination and certification by the ABPM, a pain
physician “serves as a consultant to other physicians but
is often the principal treating physician and may provide
care at various levels, such as direct treatment, prescribing
medication, prescribing rehabilitation services, performing
pain relieving procedures, counseling patients and families,
directing a multi-disciplinary team, coordinating care with
other health care providers and providing consultative services
to public and private agencies pursuant to optimal health
care delivery to the patient suffering from pain. The pain
physician may work in a variety of settings and is competent
to treat the entire range of pain encountered in the delivery
of quality health care.”
The American Medical Association’s (AMA) strategic agenda
remains rooted in commitment to standards, ethics, excellence
in medical education and practice, and advocacy on behalf
of the medical profession and the patients it serves. The
Accreditation Council for Graduate Medical Education (ACGME)
is responsible for the accreditation of post-MD medical training
programs within the United States. Accreditation is accomplished
through a peer review process and is based upon established
standards and guidelines. The ACGME sets requirements that
institutions must meet in order to sponsor Graduate Medical
Education (GME). According to the institutional requirements,
the purpose of GME is to provide an organized educational
program with guidance and supervision of the resident, facilitating
the resident's professional and personal development while
ensuring safe and appropriate care for patients.” The institutional
requirements, along with each specialty's program requirements,
guide institutions and residency programs in the process of
providing an ethical and professional environment in which
the educational curricular requirements can be met.
Understanding these new subspecialties of Pain Management
-Anesthesiology and Pain Medicine will help people find a
physician with knowledge, experience and commitment to diagnosing
and treating chronic pain such as RSD/CRPS.
Detailed Specialty for Pain Management - Anesthesiology:
The anesthesiologist who specializes in pain management is
a physician who must receive additional training in pain management
after the completion of anesthesiology training. Certification
in pain management will recognize those physician anesthesiologists
who, through special examination in pain management, have
documented competence to provide a high level of care either
as a primary physician or consultant for patients experiencing
problems with acute or chronic pain in both hospital and ambulatory
settings and coordinate a multidisciplinary approach toward
pain management. The additional training in pain management
prepares the anesthesiologist to treat patients within the
entire range of painful disorders with mastery of an additional
body of knowledge required for the diagnosis and management
of patients with pain.
The American Board of Anesthesiology (ABA) offers additional
certification of Added Qualifications in Pain Management.
The ACGME Program Requirements for Pain Management - Anesthesiology
is 1 year in Pain Management after completion of a core residency
program related to Pain Management accredited by the ACGME.
Detailed Specialty for Pain Medicine:
Pain Medicine physicians limit their practice to the evaluation
and management of individuals with acute, cancer and chronic
pain. The Pain Medicine physician has background in the neurophysiology
and neurochemistry of pain. Physicians in diverse fields of
medicine are active in pain medicine. These diverse fields
include Anesthesiology, Oncology, Neurosurgery, Neurology,
Physical Medicine and Rehabilitation, Psychiatry, Internal
Medicine, Family Practice and other subspecialties.
Two-year Pain research fellowships are available from the
National Institutes of Health (NIH). One-year Pain fellowships
are offered on an ACGME accredited basis by many anesthesiology
programs.
Physicians in specialties other than anesthesiology or anesthesiologists
who do not meet the criteria for Pain Management - Anesthesiology
can apply to become Fellows of the American Board of Pain
Medicine (ABPM) if they meet the following requirements: (1)
currently certified by one of the member Boards of the American
Board of Medical Specialties (ABMS), (2) two years in the
practice of Pain Medicine, (3) an unrestricted license to
practice medicine in one of the 50 states.
References:
1. Whitaker AL, Kennedy DT, Small RE. Adjuvant Agents for
Managing Chronic Pain. American Pain Society Bulletin.
1999;9(2).
2. Foley KM. Pain management in the elderly. In WR Hazzard,
EL Bierman, JP Blass, WH Ettinger & JB Halter (Eds.), Principles
of geriatric medicine and gerontology. New York: McGraw
Hill, 1994.
3. Wall PD and Melzack R. eds. Textbook of pain. New
York: Churchill Livingstone, 1994.
4. Montauk SL and Martin J. Treating chronic pain. American
Family Physician. 1997:55(4);451-460.
5. Onghena P and Van Houdenhove B. Antidepressant induced
analgesia in chronic nonmalignant pain: A meta-analysis of
39 placebo-controlled studies. Pain. 1994:49;205-219.
Reprinted with permission from: RSDSA NEWS, Official
Publication of the RSDSA-CA Volume 6, Issue 4 Pro Ed - November
1999 |
