Interventional Pain Medicine (IPM) a 'Solid Choice' for Avoiding Opioid Escalation

LAS VEGAS—Interventional pain medicine (IPM) is undergoing “explosive growth” but suffers from misconceptions, reported Sanford M. Silverman, MD, Medical Director of Comprehensive Pain Medicine, in Pompano Beach, Florida, and Hans C. Hansen, MD, FIPP, ABIPP, DABPM, and DABM, Executive Director of the North Carolina Society of Interventional Pain Physicians and Medical Director of The Pain Relief Centers in Conover, North Carolina.

“IPM is a solid-choice solution to avoid escalation of controlled substances and assist in diagnosis and treatment of painful conditions,” Dr. Hansen said to PAINWeek attendees. “Interventional pain medicine is a very important part of pain control strategies.”

Pain is the most common routine patient complaint in primary care settings, he noted, and membership Membership in the American Society of Interventional Pain Physicians (ASIPP) has grown from 265 members in 1999 to more than 4000 members in 2014. There's been very rapid growth in the number of interventional procedures, such as interlaminar epidurals and sacroiliac joint injections, performed over the past decade.

But fallacies and false generalizations persist about the field, including beliefs that epidurals are generally dangerous, that nerve blocks are ineffective or harmful, and an impression that “when I refer, all they want to do is injections,” Dr. Silverman noted.

Concerns about IPM have been exacerbated by television news shows, recent headlines about contamination at drug compounding facilities, FDA reports on steroids, and a “general mistrust of the unknown,” he added.

“We have not been depicted particularly favorably in the news media,” Dr. Silverman said, suggesting that concerns about IPM are exaggerated, particularly compared to other arenas of pain medicine.

In reality, he and Dr. Hansen said, IPM are relatively safe and represent a wide range of procedure types, including clinical pharmacology and neural ablation, to device implantation.

“It's more than taking a needle and putting it somewhere God never intended a needle to go,” Dr. Hansen quipped. “It's doing something meaningful and something diagnostic.”

Citing ASIPP's definition, Drs. Hansen and Silverman defined IPM techniques as “minimally invasive procedures, including percutaneous precision needle placement with placement of drugs in targeted areas or ablation of targeted nerves and some surgical techniques, such as laser or endoscopic discectomy, intrathecal infusion pumps and spinal cord stimulators, for the diagnosis and management of chronic, persistent and intractable pain.”

These techniques offer alternatives to escalating opioid or other controlled-substance therapies for pain management, Drs. Hansen and Silverman emphasized. Intrathecal drugs can help to reduce overall pharmacologic load via targeted delivery, for example. Referring clinicians should choose a pain specialist who does IPM, Dr. Silverman said.

“We're pain specialists who do interventional procedures,” said Dr. Silverman. “We don't like ‘interventionist.' If all you do is injections, I don't think you're going to do very well.”

General practitioners are the fastest-growing group of interventionists, Dr. Hansen noted.

“It is the practice of pain medicine,” Dr. Silverman added. “It's more important to know when not to do these procedures than it is to learn how to do them and generate income.”

Evaluation involves taking patient medical, psychosocial and pain history; physical, functional, and psychosocial assessments; and diagnostic tests, they noted. Impressions are documented, and a management plan is devised, taking into consideration possible rehabilitation strategies, diagnostic interventions and therapeutic interventional management options. Then the management plan is continued or a comprehensive evaluation is repeated.

IPM is also increasingly important in the diagnosis of underlying causes of pain, Dr. Hansen emphasized.

Pain is merely a symptom until it is properly diagnosed and assessed, Dr. Silverman pointed out.

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