What is a Pain Doctor?

Pain Doctor and Pain Medicine explained by Las Vegas, Summerlin, and Henderson Nevada’s Top Pain Doctors

“The aim of the wise is not to secure pleasure, but to avoid pain.” ― Aristotle
Pain Management MRIPain is unquestionably one of the greatest existential problems of mankind. Saint Augustine once remarked that “the greatest evil is physical pain,” and C.S. Lewis, in his book The Problem of Pain wrote, “If any man is safe from the danger of under-estimating this adversary [pain], I am that man.” According to the International Association for the Study of Pain, pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” If we really ponder the subject, it is difficult to describe what pain is and why it is so unpleasant. It seems to be different in humans than in many other animals. In humans it seems to be more intense and more connected to psychology, behavior, and emotion. Almost all of us know that pain does not reliably scale with level or severity of tissue injury—sometimes a small wound such as a shallow cut or abrasion inflicts excruciating pain. Pain is subjective—we learn as children how to communicate about our pain. It is often associated with adverse health conditions and is the most common motivation for doctor visits in the U.S.

Regardless of how well we can conceptualize it and describe it in language, pain is an essential part of the human experience. It is a crucial messenger—it warns us of potential or actual harm and prompts us to escape from its cause. But pain may keep speaking even after we have heard and responded to its message. It may be debilitating and may dramatically reduce quality of life.

At Nevada Pain, we treat every patient as if they were our own mom or dad. We call this the “Mom and Dad Test.” The test is one of the founding principles of our practice and something each and everyone of our staff members holds dear to them.

Watch This Video and Learn About The Mom and Dad Test

Fortunately, today we have pain doctors—physicians who have specialized in treating and helping us cope with pain. These doctors have a diverse medical skill set consisting of an ever-growing body of knowledge and expertise in managing and eliminating pain at its sources. Here, we will explore in more detail what a pain doctor is, what interventional pain doctors do, the training involved in becoming a pain doctor, and what types of care they provide. We will then describe how pain doctors diagnose and treat pain at its source. While there are a variety of approaches to mitigate and treat pain including shamanism, chiropractic, acupuncture, acupressure, homeopathic and traditional herbal medicine, and allopathic or “western” medicine, it is allopathic medicine that we will be considering below.

What is a Pain Doctor?

Pain DoctorThe field of allopathic medicine is rapidly growing and is almost as vast and complex as the human body for which it exists. For these reasons, the process of becoming a medical doctor is lengthy and involves rigorous training. Not only that, but medical technology advances at an extremely rapid pace as scientists worldwide make new medical discoveries daily. No one doctor, no matter how talented, can possibly stay current on all human health topics—the body of information is simply too vast and rapidly expanding. Therefore, some doctors specialize in one or a few related areas of medicine after they complete their foundational medical training. This is certainly not to say that primary care doctors are inferior. In fact, their role is a difficult one: to keep up to date on all health topics and monitor the overall health of their patients. Primary care doctors typically refer their patients with conditions they cannot manage to specialists who focus their entire professional attention on these conditions. Specializing has many advantages, most important of which are the abilities to stay current and provide the best, most well-informed patient care in specific areas.

Pain management, or pain medicine as it is interchangeably referred, is one of the medical specialties a doctor may choose during his or her training. While pain itself has been a human health problem since the beginning of written language (e.g. The Book of Job), pain management as a defined medical specialty in the U.S. is fairly young, dating back only into the late 1980s and early 1990s. Before the field came into its own, pain medicine was largely a side activity that anesthesiologists did, if they had time. They largely managed pain more often than treated the causes of the pain. Now, a pain doctor is one who specializes in pain management and serves as an expert in identifying and treating the sources of pain. By focusing attention on pain and the causes of pain, a pain doctor does not replace the primary care doctor. Rather, he or she depends upon the primary care doctor to monitor the overall health of patients and provide clues for why the patients referred to the pain doctor are experiencing pain. The pain doctor is the one equipped with the most up-to-date tools and information for diagnosing and treating both acute (short-term or intermittent) and chronic (long-term or intractable) pain and may work cooperatively with the primary care doctor in identifying and treating the sources of pain.

In order to diagnose, manage, and treat it, a pain doctor must thoroughly understand pain. There are a variety of physiological types of pain, including nociceptive, neuropathic, incident, psychogenic, and a few less common types associated with specific health conditions. Nociceptive pain is caused by activity in the specific type of pain nerve fibers that conduct noxious, injurious, or thermal pain information. Neuropathic pain is caused by abnormal stimulation of the nerve fibers that conduct non-pain information such as body position and pressure. Incident pain is the pain associated with movement and activity such as moving an achy joint or pressing on a bruise or wound. Psychogenic pain is caused by or made worse by behavioral, mental, or emotional factors and can be thought of largely as “mind over matter” types of pain, including upset stomachs from anxiety and also headaches associated with depression. Other types of less common pain include phantom pain in amputees and cancer pain. A pain doctor should be familiar with diagnosing and treating all of these types of pain in their acute and chronic states. Therefore, a pain doctor has to be good at evaluating the biological, chemical, physical, emotional, and behavioral patient states. This is a daunting task.

What is an Interventional Pain Doctor?

Pain Doctor ExplainationAn interventional pain doctor is a pain doctor that practices in the subspecialty of pain medicine that involves invasive procedures and techniques for controlling pain. One of the oldest techniques in interventional pain management is the resection or cutting of the pain fiber tracts that run longitudinally in the spinal cord. Because pain nerves enter the spinal cord all along the vertebral column and because pain nerve fibers run together in their pathways to the brain, a pain source can be located and then blocked by cutting the spinal cord area that carries pain just above where the offending nerve enters. This procedure resulted in cessation of pain from all areas of the body at and below the nerves entering the spinal cord below the level of the cut. To illustrate, a series of homes along a straight, dead-end road are connected to phone service with one main phone cable that branches off at each house until the cable reaches that last house and ends. If the cable is cut somewhere along the road, all of the houses from where the cable is cut to the end of the road lose phone service. The same is true for a cut in the pain fibers of the spinal cord. All connections below the level of the cut stop communicating their information to the brain. However, the nerves coming from the various body parts still communicate with the spinal cord for reflex responses to occur, although the patient no longer feels pain stimulation from those parts. Obviously, this is a radical, invasive, and permanent procedure that was used as a last resort in treating intractable pain. This particular approach is rarely used nowadays.

Today, interventional pain management has at its disposal a number of advanced and sophisticated procedures that vary in their invasiveness and permanence. Which procedures are used mostly depends on the underlying condition that is causing the pain. For example, radiation may be used to control the cancer-related pain of bone metastases or tumor-caused nerve squeezing. Low doses of radiation can have pain-reducing effects, although the mechanism for this is not well defined. Spinal cord and deep brain electrical stimulation are techniques used for some cases of non-cancer-related pain. Other procedures depend on pharmacological agents such as opioid drugs and anesthetics. These may be infused just outside of (epidural) or just inside of (intrathecal) the dura mater, a tough, protective covering of the brain and spinal cord. These techniques deliver drugs locally to nerve cells involved in pain sensation rather than allowing them to circulate through and numb the entire body via intravenous injection. It is these tools and others that equip the interventional pain doctor to be a particularly aggressive and often effective treatment provider in some of the most difficult pain cases.

What is a Pain Fellowship?

Pain FellowshipMedical training in the United States and Canada involves multiple stages over many years. In general, medical school applicants have already completed a four-year bachelor’s degree at an accredited college or university (or at least roughly three years of required coursework) and have scored well on a generalized medical entrance exam. The medical school application and selection process is rigorous, and only the most talented applicants are selected. Medical school programs typically involve four to five years of continuous training including coursework in core subjects in the first half followed by clinical rotations under close supervision. Some medical students may seek additional training for a short period between these two phases of medical school (e.g. a year of public health training). Medical school training provides a broad-range medical training over most human health topics.

Upon successful completion of medical school, students begin one or more internships that usually last for one year. At this stage, medical students have their degrees conferred but have usually not been fully licensed to practice medicine without supervision. This is the stage at which doctors may begin to specialize in a particular area of interest. Upon completion of this internship and passing the final stage of the licensing examination process, a doctor may be licensed as a general practitioner. Many doctors, however, seek further supervised experience in their specialty in what is called a medical residency. It is common for the year-long internship to become a residency in subsequent years. In the U.S., nearly all doctors complete a residency program. These residencies may last two to seven years, and a doctor with an interest in a pain management career is usually well on their way at this stage with becoming a pain doctor.

After a doctor successfully completes a residency, they may seek a training fellowship with an accredited program within their chosen specialty. Fellowships last one or more years, during which fellows may act as attending or consulting physicians in their general field of training. Upon completion of the fellowship, the doctor is permitted to practice independently by other doctors practicing in the specialty. Board certification usually occurs at this stage after successful completion of the written and oral certification exams.

A pain fellowship is a fellowship in pain management or pain medicine. As explained, the medical fellowship is often a doctor’s final stage of training in her specialty and for a pain doctor, the pain fellowship is a capstone experience before being certified and practicing independently in pain management. There are a number of academic medical institutions in the U.S. with pain fellowship programs, and many tend to be housed within anesthesia departments. The American Pain Society maintains a list of domestic pain fellowship programs on their website. Many programs consider applicants with primary training in several specialties, including Anesthesiology, Neurology, Physical Medicine and Rehabilitation, and Psychiatry. Anesthesia residents tend to be the largest group of applicants for pain fellowships. Each program usually accepts a very small number of fellows each year (as few as one to three), and competition for pain fellowships is high. Some programs are offering a second year to successful year one fellows.

Pain fellowship programs may have accreditation by the Accreditation Council for Graduate Medical Education (ACGME) and are mostly housed in academic research and training hospitals. There are over 100 ACGME-accredited pain fellowship programs, the vast majority of which are in anesthesia, whereas about ten to twenty percent may be in other areas such as physical medicine and rehabilitation. Pain fellows typically commit to twelve months of both in- and outpatient care with a focus on evaluation and management of a variety of pain cases including acute, chronic, and cancer pain. Because of the vast array of conditions that cause pain, the pain fellow trains in a multidisciplinary environment, working closely with other specialists including surgeons and neurologists. Moreover, pain fellows learn to utilize all of the available pain treatment modalities including pharmacological, non-pharmacological, surgical, implant-based, and non-surgical procedures with varying levels of invasiveness and permanence. One important goal of the pain fellowship program is to provide experience in both basic and advanced pain management procedures including sympathetic blocks, neurolytic techniques, head and neck blocks, neuraxial injections and blocks, ultrasound-guided injections and blocks, and headache-specific management procedures. Fellows may also participate in a variety of didactic studies as well, including lectures, seminars, and conferences. It is a lot to pack into one year, and pain fellows are kept very busy during their final phase of training.

Pain fellows may also learn the business and management side of pain medicine as well as participate in research projects. Pain fellowships prepare pain doctors for a demanding career in a complex field while enabling them to earn the necessary board certification to practice pain medicine without supervision. One noteworthy distinction for successful pain fellows is the Certificate of Added Qualification in Pain Management offered by the American Board of Anesthesiology. Patients are encouraged to review the credentials of their pain doctors.

What is Comprehensive Care?

Comprehensive Care - ChiropractorComprehensive care in medicine is a general term for an evaluation and treatment paradigm that focuses on the specific health condition for which the patient is seeking care as well as the overall health and well-being of the patient. There is a greater emphasis in comprehensive care on the effect comorbidities (concurrent illnesses) have on the condition of interest and a decrease in the reductionist approach of isolating and treating individual conditions. The underlying philosophy is that isolating and treating a particular health condition may be of limited success in the presence of other health complications in the patient, even if those other health issues appear to be outside of the causal pathway for the specific condition being treated. For example, chronic conditions like diabetes mellitus, kidney disease, or cardiovascular disease and their implications are considered when evaluating and designing a treatment strategy for a specific condition like achy joints. While these chronic conditions may not typically cause achy joints directly, they may cause other underlying alterations in the patient’s physiology that contribute to a condition that does cause achy joints. Without a comprehensive approach to the achy joints in this example, the treatment may only be temporarily effective, if at all. In contrast, the comprehensive care approach may involve, among many things, a short-term alleviation of the pain from the achy joints as well as some longer term plans for improving the overall health of the patient. Progress toward that goal of overall health may be periodically assessed with a number of exams and quantitative measurements. Most importantly, a patient with one or more underlying chronic illnesses will likely need to consult with more than one medical specialist, and the specialists involved in the patient’s care will communicate with each other directly.

Also in general terms, comprehensive care, in an effort to address all of a patient’s needs for and relating to their condition for which they are seeking treatment, may address a variety of para- or non-medical issues, by a staff that is skilled in the specific areas of need. These issues are within but not limited to the areas of emotional, psychological, educational, social, and family situations. The pain management team is multidisciplinary and capable of thorough evaluations of physical, biological, and psychosocial factors in the pain condition. The comprehensive care paradigm is developing in more and more anesthesiology departments as well as in other programs such as physical medicine and rehabilitation. The successes of the comprehensive approach have been demonstrated in other medical fields such as hemophilia and cancer. Because pain is a complex condition best addressed from multiple perspectives, it is a particularly good candidate field for the comprehensive care approach.

One particular area of pain management where the comprehensive care approach has been successfully implemented is in the precarious balance between pain pharmacotherapies with opioid drugs and addiction to these drugs. The management of a pain condition with opioid drugs can lead a patient into addiction and therefore, the use of opioids must be closely monitored by the pain doctor and the management team. Before the opioid strategy is implemented, there should be a clearly defined goal in mind and a plan for discontinuing the drug use. Many pain patients, particularly those with comorbidities such as depression, are candidates for the extra supervision that the comprehensive care approach is able to maintain. It is important for a comprehensive pain care team to be ready to be assertive in controlling the development of opioid addiction.

How Does a Pain Doctor Diagnose Your Pain?

It is normal to feel different as we age. We may experience various aches and pains that were never present before or that become more frequent and stronger as we get older. Physical activity may cause achy joints and tendons and perhaps greater muscle pain than before. However, being in pain that is different from the usual activity-associated soreness is a sign that something is not right. Of course, pain can strike at any age so it is important to realize that pain is a warning signal that something may be wrong whether one is young or old. If you experience a pain that interrupts sleep or other normal life activities such as work, exercise, daily household tasks, or socializing, for more than a week or two, then it is time to schedule a visit with your primary care doctor as a first step. If they find that you have pain that may be associated with a condition that they cannot manage and treat in their clinic, they may refer you to a pain doctor. The goal of seeing a pain doctor is threefold: find out what is causing the pain, begin a plan to manage the pain in the short term, and develop a plan to treat the underlying cause of the pain in order to reduce or eliminate the pain altogether.

When a patient seeks medical help from a specialist for pain, the first thing a pain doctor must do is make a correct diagnosis. This begins with working closely with the patient’s primary care doctor to get as much information as possible on the patient’s history and overall health. They will also collect a self-reported health history from the patient directly. These pieces of information yield important insights into what might be causing the pain. The pain doctor will usually perform a complete physical exam and ask the patient to describe the pain in detail in terms of location, duration, and what seems to aggravate and alleviate the pain. Pain conditions vary widely and in general fall into either the acute or chronic category. The defining qualifications for which type of pain is present are varying but in general, chronic pain is defined as either pain lasting more than six months or beyond the reasonable expected time of healing for the suspected root cause. Pain of either category may be very difficult to correctly diagnose because different causes can sometimes produce very similar pains, and pain that is diffuse may not locate to where the actual cause is located. The pain doctor may order imaging, laboratory tests, and other diagnostic procedures in the diagnostic process. They will carefully consider all information in their evaluation and consultations with the primary care doctor and strive to correctly diagnose the pain in terms of root cause so that proper treatment may be planned.

The pain diagnosis process may include some familiar things like X-rays and blood draws. The pain doctor may also order procedures the patient may have heard of but has never experienced before. These include powerful imaging techniques including computed tomography (CT), computed axial tomography (CAT), and magnetic resonance imaging (MRI). These imaging techniques use radiation (CT and CAT) or electromagnetism (MRI) to produce high-resolution images of internal tissues and may reveal abnormalities or injuries in these tissues. Ultrasound is another imaging technique that may be ordered for looking inside the body. All of these techniques are non-invasive. Discography and myelogram are ways to improve the information gained by X-ray by introducing contrast agents into the intervertebral disc or area of the spinal cord and nearby nerves that may be a source of pain. Disorders in bone often cause pain that may be difficult to diagnose, so a pain doctor may order a bone scan that relies on a small amount of radioactive substance that seeks the bone after injection. This material may then provide a measurable signal used for bone imaging. The images may reveal fractures, infections, or other problems in an affected bone. Together, these and other diagnostic procedures and techniques form a powerful toolkit for the pain doctor to use in diagnosing pain conditions. A correct diagnosis is crucial for effective subsequent management and treatment.

Diagnosing pain conditions may be an iterative process. That is, the pain doctor may make an initial diagnosis, implement an initial management strategy, and assess the strategy’s effectiveness in mitigating the pain. Depending on the level and duration of pain reduction, the pain doctor may continue with their initial diagnosis or change course in the diagnostic process. A pain doctor may order evaluations by other specialists as well. These evaluations may be done by a psychiatrist, neurologist, or other medical professional. The doctors then consult with one another in refining the diagnosis. Most pain conditions can be traced to their sources, and most can be treated. A correct, thorough diagnosis is the first step in this process.

How Does a Pain Doctor Manage Your Pain?

A pain doctor who uses a comprehensive care approach to treating pain has a difficult, complex job to do. They have to coordinate the efforts of a team of pain management players, and accurate foresight and timing are essential. Imagine your pain doctor as a star quarterback of a football team. The “end zone” is effective management of your pain and the way the pain quarterback leads the offense to a touchdown in that end zone is to coordinate all the players in the team in a play-by-play march down the field, always making forward progress. The pain doctor has to constantly observe what the opposing team’s defense is doing—how those players are causing your pain—and design a series of plays that puts them back on their heels and keeps them off balance. As the leader of the team, the pain quarterback has to know his or her opponent and know how to respond to what the opponent does.

The pain quarterback cannot be an effective team leader without support. He or she takes information and suggestions from the sidelines, where observers are studying the defense’s movements from vantage points the quarterback himself cannot attain while on the field. The doctor’s team members on the field also relate their observations each time the team huddles to plan the next play. The pain doctor knows the talents and strengths of his or her team members, and has a deep playbook from which to choose each consecutive play in the orchestration of the scoring strategy.

The pain quarterback calls a play in the huddle, each team member moves into position, but right before calling the cadence that tells the center to snap the ball and set the play in motion, the quarterback has to quickly look at the defense to make sure the play has a fair chance of working. If the defense has changed its configuration, the pain quarterback has to think lightning-fast and “call an audible”—shouting out a code that the team understands as a change to the play, or as a whole new play, just moments before executing the play. A pain doctor has practiced these maneuvers with his or her teammates dozens of times so that they hear and understand the directions correctly.

At the pain doctor’s command, the quarterback receives the snap and sets the play in motion. He or she watches the team execute their roles in concert with one another, and monitors how the opponent responds, all the while the pain doctor is executing his or her own role in the play, which is to advance the team down the field toward the end zone. How the team makes this forward progress depends on the play. The pain quarterback may take the ball and head down field. They may hand the ball off to one of the running backs, or he or she may pass the ball over the heads of the defense to one of the receivers who have shot downfield. The quarterback depends on all teammates fulfilling their assigned duties and if they do, they make forward progress against their opponent—your pain.

After each play ends, the quarterback gathers the offense into a huddle to call the next play. The pain doctor has to assess the previous play and consider what the opponent did to limit the offense’s forward progress. If the play was successful, then the pain doctor may call a similar play. However, if the team made only small progress, he or she must quickly determine why and decide whether a new and different type of play will be more effective. These are skills that the quarterback has developed over time with practice and experience. Over the course of training and game play, the pain doctor has honed his or her knowledge, developed a vast playbook, and acquired a seasoned wisdom that only comes with time on the field and learning from mistakes.

This playful analogy of a pain doctor as a football quarterback illustrates the importance and complexity of the pain doctor’s role in managing a patient’s pain while having to keep a watchful eye on the pain, its underlying cause, as well as the overall health and well-being of a patient. The pain doctor’s challenge comes first in diagnosing the root cause of a patient’s pain. Then he or she must coordinate the activities of a team of comprehensive care professionals who all play an important role in the management and treatment of the pain. The pain doctor must assess the progress of each phase of the treatment plan and make adjustments as necessary until he or she leads the  team into the end zone of effective pain treatment. It is important to note that often the management of pain is what accounts for small, incremental forward progress, whereas the treatment of any underlying problem or condition is ultimately the end goal or “touchdown” in our football analogy.

The pain doctor’s playbook is deep with solutions tailored to address a variety of problems. These strategies and interventions include drugs ranging from nonprescription aspirin and other non-steroidal anti-inflammatory drugs (ibuprofen, acetaminophen, etc.) to mild anesthetics to restricted opioids. There are a variety of more invasive procedures including direct injections of steroidal anti-inflammatory agents, anesthetics, and anxiolytics. Comprehensive care paradigms may include psychiatric evaluations and treatments and even some alternative approaches such as chiropractic, acupuncture, and homeopathic remedies. The approaches to managing and treating pain vary with the doctors and their talents and experiences. It is important for the pain patient to feel comfortable with the doctor treating their particular pain.

Conclusion

Pain is a complex sensory and emotional experience that everyone has to deal with. We all live with various aches and pains moment by moment but when pain begins to limit our lives in one or more ways, then it is likely telling us that there is a problem that needs attention. A patient with debilitating pain begins with an evaluation by a primary care doctor who may refer the patient to a pain doctor.

Pain doctors specialize in diagnosing, managing, and treating pain at its sources. There are varying levels of invasiveness in interventional pain management and treatment, and which one works best depends on the condition causing the pain. Managing pain is tricky because the interventions have drawbacks and in the case of some drugs, addiction and dependency are potentially as debilitating as or more debilitating than the pain for which they were originally administered. What is more, pain as a condition is a very complex medical problem because of the overlap in causes and inconsistent scaling with severity of cause. Mental, emotional, and behavior factors contribute to pain as well. Altogether, these facets of pain make for a substantial challenge for any pain doctor attempting to manage pain.

Even so, this medical specialty has advanced rapidly in recent years with a move toward comprehensive care whereby a team of professionals attempt to address the various needs of the whole pain patient and not simply mitigate the pain. The training programs for new pain fellows are slowly expanding and beginning to address the greater demand for pain doctors in the U.S. No one has to live with debilitating pain—there are highly trained pain doctors ready and eager to help.

Professional Organizations and Resources

Accreditation Council for Graduate Medical Education — www.acgme.org

American Academy of Pain Medicine — www.painmed.org

American Board of Anesthesiology — www.theaba.org

American Board of Medical Specialties — www.abms.org

American Board of Pain Medicine — www.abpm.org

American Board of Physical Medicine and Rehabilitation — www.abpmr.org

American Board of Psychiatry and Neurology — www.abpn.com

American Pain Society — www.americanpainsociety.org

American Society of Regional Anesthesia and Pain Medicine — www.asra.com

International Association for the Study of Pain (IASP) — www.iasp-pain.org

World Institute of Pain — www.worldinstituteofpain.org

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