Finding an RSD Specialist

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) The APS article 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, prostaglandins, 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 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 amitryptyline (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 ® ) & 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.<O:P></O:P>

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 multidisciplinary 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 (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) oversees residency training programs and training institutions in the United States.  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 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 neurochemisty 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, Psychiarty, 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 College 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. Adjuvant Agents for Managing Chronic Pain, Amy L. Whitaker, PharmD; Daniel T Kennedy, PharmD BCPS; Ralph E Small, PharmD PCCP PASHP PAPhA, American Pain Society BULLETIN, March/April 1999- Vol 9, #2.
2. Foley, KM, (1994), Pain management in the elderly. In WR Hazzard, EL Bierman, JP Blass, WH Ettinger & JB Halter (Eds.), Principles of geriatric medicine and gerontology ( 3^rd ed., pp. 317-331) New York: McGraw Hill.
3. Meyer, RA; Campbell, JN; & Raja, SN; (1994) Peripheral and neural mechanisms of nociception. In PD Wall & R Melzack (Eds) Textbook of pain ( 3^rd ed., pp 13-44) New York: Churchill Livingstone.
4. Bennett, GF (1994) Neuropathic pain. In PD Wall & R Melzack (Eds.), Textbook of pain (3^rd ed., pp 201-224) New York: Churchill Livingstone.
5. Craig, KD (1994) Emotional aspects of pain. In PD Wall & R Melzack ( Eds.), Textbook of pain (3^rd ed., pp 261-274) New York: Churchill Livingstone.
6. Montauk, SL; and Martin J; (1997) Treating chronic pain, American Family Physician, 55(4), 451-460.
7. Onghena, P; & Van Houdenhove B; (1992). Antidepressant induced analgesia in chronic nonmalignant pain: A meta-analysis of 39 placebo-controlled studies. Pain, 49-, 205-219.