Pain Management

Pain, especially in the hospital, is such a prevalent problem. All physicians (except perhaps radiologists and pathologists) have some facility in treating pain. One of the first things we learn in residency is opiate management, quickly followed by learning the bowel regimen (since opiates commonly cause constipation). For the most part, doctors do just fine. So when do you need a consultation from a pain management specialist?

The pain subspecialty is made up of multiple specialties: anesthesiology, neurology, psychiatry, and physical medicine and rehabilitation. Thus, it is a highly interdisciplinary field that draws tools, skills, and strengths from many different areas. We approach pain in a multimodal manner; from a nonpharmacologic standpoint, we address psychological issues, psychiatric comorbidities, addiction, expectations, physical and occupational therapy, biofeedback, acupuncture and acupressure, meditation, massage. With medications, we use not only opiates, but opiates in many delivery systems: patient controlled analgesia, intrathecal administration, epidurals, transdermal delivery. We use the opiates other physicians fear: meperidine, suboxone, methadone, and sky-high doses of mainstream medications. And along with our multimodal approach, we use nonopiate adjuncts: acetaminophen (both orally and IV), NSAIDs, neuropathic agents, tricyclic antidepressants, selective norepinephrine re-uptake inhibitors, local anesthetics (both locally and intravenously), NMDA antagonists like ketamine.

Lastly, the pain service can do invasive procedures for pain. We block nerves under fluoroscopy in the operating room or ultrasound guidance at the bedside. We do trigger point injections with botox. We place continuous pump infusions into the spinal space. We do pulsed radiofrequency treatments, ablation of nerves, and implantation of spinal cord stimulators. I've done a few nerve blocks and it's incredibly satisfying to see the relief patients get. It's really a fascinating specialty.