5 Trends in Pain Management With Dr. Ira Fox of the World Institute of Pain

The sixth World Congress of the World Institute of Pain, which brings together pain specialists from around the world, begins tomorrow in Miami. Ira Fox, MD, DABPM, FIPP, ABIPP, founder, Anesthesia Pain Care Consultants in Ft. Lauderdale, Fla., and chairman of the advisory board for the World Institute of Pain executive board, shares five insights into the biggest trends at this year's event.
1. Opioids have a place in pain management but need to be used responsibly. One of the biggest topics in pain management is the use of opioids to treat pain, Dr. Fox says. Following the CDC report outlining the prescription drug abuse in this country, the crackdown on "pill mills" has increased.

"Especially in South Florida, where we've had a lot of recent issues resulting in the closing down of pill mills, it's a topic which requires attention," he says.

Dr. Fox says the negative effect the pill mills have had on the reputation of interventional pain management is mostly a perception problem.

"People don't understand that what we do as pain specialists entails not only the use of medication but also interventional techniques," he says. "Having said that, there's a role for medication management, but it has to be done in a responsible fashion."

Dr. Fox says it's important for pain specialists to implement certain standards, such as random drug testing and narcotic contracts, into medication management to ensure patients are taking the prescribed medication and that it's not being diverted. However, prescribing opioids can be a valuable part of what pain management physicians do if it's done correctly.

"[Physicians should] prescribe opioid medication in certain instances where it makes a difference and allows people to improve their quality of life," he says. "That's one of the topics that has become extremely relevant given the climate we're practicing in."

2. The use of spinal cord stimulation is expanding. Dr. Fox says that although spinal cord stimulation is not a new technology, it's being applied in new ways. Traditionally, spinal cord stimulation entailed placing leads into the spine to block pain impulses to the rest of the body. While that technique is still being done, Dr. Fox says there's a move toward peripheral or field stimulation in which leads are placed under the skin in different parts of the body.

"In doing that, we can obtain some additional ability to block pain coming from different areas," he says.

Dr. Fox says another method called hybrid stimulation, in which leads are placed into the spine itself as well as into other areas of the body, is becoming more common.

"A typical example of that is placing a spinal cord stimulator lead into the spine blocking impulses that may radiate down into somebody's leg," he says. "You would also place stimulation leads under the skin in the lower back area as well in order to augment relief of back pain."

3. Pain physicians are moving into minimally invasive spine surgery.
Dr. Fox says pain specialists are becoming more and more involved in minimally invasive spine procedures, including lumbar decompressions, intradiscal procedures and disectomies. With intradiscal procedures, physicians actually go in and remove part of the disc. With radiofrequency procedures, physicians eliminate pain pathways. Dr. Fox says this is a slight departure from traditional epidural steroid injections and other common pain management procedures.

"Historically, pain specialists have done procedures in the spine, such as injections and nerve blocks," he says. "That has been bread-and-butter interventional pain management for many years. Certainly, within the last 20 years, that has been the mainstay and foundation of what we do. Since that time, we've become more involved."

4. There's a push toward evidence based medicine and more guidelines. Evidence based medicine is a major buzzword in pain management right now, and most sessions at the congress will touch on it in some way. However, Dr. Fox says evidence based medicine has its pitfalls, especially in a specialty like pain management where outcomes are so dependent on a physician's individual technique.

"From a personal level, I think evidence based medicine is not quite that simple because there's definitely a benefit from someone whose technique is a little bit more proficient," he says.

Dr. Fox says the push toward evidence based medicine will continue as payors and patients increasingly want evidence to back up claims that a certain treatment will be beneficial. In addition to evidence based medicine, there's also a push to develop more guidelines for interventional pain management.

"Unfortunately, insurance companies have looked at those guidelines as the rule and have used those to deny care instead of get patients care," he says. "Guidelines are lightning in a bottle. They can be used in ways that are really not helpful. We need to be careful not to put everyone in a cookie cutter as a patient."

Dr. Fox says guidelines should be used to streamline the authorization process rather than deny care. For example, if patients fit all of the guidelines, they should be readily approved through the process. But, if patients don't fit all the criteria, their cases should be evaluated on an individual basis.

5. Board certification will allow for separation. Another result of the increased scrutiny on pain management physicians is non-certified or non-fellowship-trained physicians performing pain management procedures. Like prescription drug abuse, this threatens the reputation of the specialty as well as the safety of patients, Dr. Fox says. The World Institute of Pain offers a certification exam at the congress that uses cadavers so examiners can actually watch pain physicians perform certain procedures.

"Our exam has been very unique and the first of its kind to make sure that in order to be certified, you are able to perform procedures on a cadaver in a safe and competent manner," he says.

Even though certification is not required to practice, Dr. Fox says he's proud of the physicians who decided to become certified, either through the World Institute of Pain or the other associations that offer certification, because it represents the enduring spirit of pain physicians.

"I think that's what makes pain specialists a special group right now is that we have fought through an evolving specialty through the past 20 years," he says. "We have attacked an important problem that affects a lot of people. When we started, we were working in a system without billing codes and we had to establish evidence based medicine as practitioners caring for patients. We're doing it, and we're going to continue to improve upon that."

For more information on Anesthesia Pain Care Consultants, click here.

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