Interventional Pain Management: What PCPs Should Know (Q&A)

As primary care physicians are increasingly tackling medical comorbidities, establishing a collaborative relationship with pain management specialists can prove beneficial for all. Robert Bolash, MD, Assistant Professor of Anesthesiology, Department of Pain Management, Cleveland Clinic, answers these questions about pain management. He works with primary care providers to treat patients with acute, chronic or acute on chronic pain.

When should a primary care physician refer a patient?

Dr. Bolash: That really depends on the comfort level of the primary care provider and the complexity of the patient. At times, we receive referrals to endorse an ongoing treatment strategy created by another physician, while at other times we evaluate a patient for a new or refractory diagnosis.

How do you evaluate a patient?

Dr. Bolash: Almost universally, patients will tell us, “pain is pain,” but in fact, it is much more complex. We work through the pain complaint often using a physician-directed history to understand the nuances and reach a diagnosis. Once we have a diagnosis, we discuss treatment options, some of which can continue back in the primary care provider’s office.

What types of interventional treatments are available?

Dr. Bolash: While epidural steroid injections are well known, there are a much broader range of spinal and non-spinal injections, as well as minimally invasive surgical procedures and a growing number of implantable devices now available. Pain physicians select from a variety of approaches or techniques and tailor treatment based on each patient’s unique pain condition.

Should every patient receive an injection?

Dr. Bolash: In general, interventional pain procedures are reserved for relatively focal pain areas like a particular joint rather than diffuse polyarthralgias. Studies have largely disproven the effectiveness of interventional treatments (such as trigger point injections) for widespread pain conditions like fibromyalgia. Treatment should always be tailored to a diagnosis, and some pain conditions are better treated with noninterventional approaches.

What are the advantages of interventional therapies?

Dr. Bolash: Interventional pain therapies continue to serve as an effective treatment option for patients suffering with select acute, subacute and chronic pain conditions. Joint injections, nerve blocks and epidural injections have been associated with functional improvements, cost savings and require little or no downtime for the patient.

Can you tell us more about selecting patients for pain treatments?

Dr. Bolash: I can’t overemphasize enough the importance of the correct diagnosis. When the diagnosis and the treatment don’t align, the patient is unlikely to realize benefit from a pain treatment plan. That includes medications or injections. In addition to a pain diagnosis, an evaluation of medical comorbidities, an assessment of patient expectations and a risk-benefit analysis are always necessary.

It’s also important to remember that psychiatric diagnoses can make a pain assessment more complicated. Depression and anxiety are common, but a physician should also assess for psychosis and suicidal tendency. There are black box warnings for many commonly used pharmaceutical treatments, and overlooking a patient’s comorbidities could worsen a psychiatric diagnosis.

Is anticoagulant use considered by the pain practitioner?

Dr. Bolash: Bleeding complications are rare following interventional pain procedures, but physicians are paying closer attention to the expanding list of anticoagulants in contemporary use. As the number of anticoagulants increases, each drug warrants specific consideration prior to a pain procedure. New sensory or motor changes shortly after an interventional procedure always warrant a physical exam.

What about implantable devices?

Dr. Bolash: With advancements in technology and a growing body of outcome data, greater numbers of patients are now able to get relief from implantable devices such as spinal cord stimulation. Data from Cleveland Clinic and other hospitals have shown that when utilized for select pain diagnoses, certain implantable technologies are more cost effective than repeated nerve blocks, medical management or surgery. Complex regional pain syndrome is a good example of where we often try to introduce the spinal cord stimulation soon after diagnosis.

What about MRI and implants?

Dr. Bolash: I wish I could give one answer to that question, but with a growing number of new and legacy devices, each patient really requires a device-specific answer. Each implant manufacturer maintains a support hotline with a national patient roster staffed to answer some of these questions. The implanting physician can also provide guidance, and some patients may be required to visit the pain center to make adjustments to the implanted hardware around the time of obtaining advanced imaging. Many of these devices should never be exposed to MRI, and serious adverse events have been reported. We often work with physicians across a variety of specialties to find safe alternative imaging modalities.

How do costs play a role in chronic pain management?

Dr. Bolash: In a few cases, payors are beginning to see the cost savings that can be realized by use of interventional therapies over long-term medical treatments or surgery. This may become more important over the next decade as more patients join Accountable Care Organizations that provide lump sums of payments for treatment of episodes of care. We can optimize care and ultimately save healthcare costs by offering tailored pain therapies to select patients who suffer from acute and chronic pain conditions. With more than 100 million Americans suffering from chronic pain, there is a lot of opportunity to give people some relief.