Now is the time for acute pain medicine specialists

american society of anesthesiologistsA guest column by the American Society of Anesthesiologists, exclusive to

Since September is Pain Awareness Month, it’s time to recognize that not all pain is equal.

Chronic pain can be alleviated, but “acute” pain (sudden onset, brief in duration, often with an identifiable cause) must be eliminated. This requires a systems-based approach led by physicians dedicated to understanding the physiological processes associated with acute pain and investigating new ways to treat it. The solution is definitely not to give patients more and more opioids.

As our understanding of pain mechanisms has evolved, some physicians have developed a special focus on pain medicine in the acute injury, illness and perioperative settings that has led to the rapid advance of interventions to effectively manage this type of pain. Acute pain medicine involves the routine use of multiple therapies at the same time (i.e., multimodal analgesia) in the hospital  to reduce the intensity of acute pain and minimize the development of debilitating chronic pain, a problem that can result from even common surgical procedures or trauma. Unfortunately, the need for specialists in acute pain medicine is increasing.

Fortunately, graduate medical education is evolving to meet this demand.  In the fall of 2014, the Accreditation Council for Graduate Medical Education (ACGME) approved regional anesthesiology and acute pain medicine to become the next accredited subspecialty within anesthesiology. How does this differ from the already-established fellowship program in pain medicine? In the one-year multi-disciplinary pain medicine fellowship program, there is a requirement for an “acute pain inpatient experience.” However, this requirement may be satisfied by documented involvement with a minimum of 50 new patients and is not the primary emphasis of fellowship training in the specialty. Pain medicine is a board-certified subspecialty of anesthesiology; however, graduates from physical medicine and rehabilitation or psychiatry and neurology residency programs can apply for the one-year program.

A new subspecialty fellowship training program in acute pain medicine will focus on improving patients’ in-hospital pain experience. Such a program would advance, in a positive and value-added  manner, the present continuum of training in pain medicine. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is administered to a random sample of patients who have received inpatient care and receive government insurance through the Centers for Medicare and Medicaid Services (CMS). The survey consists of 32 questions and is intended to assess the “patient experience of care” domain in the value-based purchasing program. A hospital’s survey scores make up 30 percent of the formula used to determine how much of its diagnosis-related group payment withholding will be paid by CMS at the end of each year. Of the 32 questions, seven directly or indirectly relate to in-hospital pain management.

Why should acute pain medicine be a subspecialty of anesthesiology? Anesthesiology is a hospital-based medical specialty, and physician anesthesiologists focus on the prevention and treatment of pain for patients who undergo surgery, suffer trauma, or present for childbirth on a daily basis. Further, history supports the evolution of acute pain medicine through anesthesiology. The concept of an anesthesiology-led acute pain management service was first described  in 1988, but arguably the techniques employed in modern acute pain medicine and regional anesthesiology date back to Gaston Labat’s publication of Regional Anesthesia: its Technic and Clinical Application in 1922.

We need physician leaders who can run collaborative acute pain medicine teams and design systems to provide individualized, comprehensive, and timely pain management for both medical and surgical patients in the hospital. Our next generation of fellowship trained acute pain medicine specialists must possess the knowledge, skills and abilities to efficiently manage a high volume of inpatient consultations, anticipate the analgesic needs of a wide range of patients based on preoperative risk, use a multimodal approach to manage and prevent pain when possible, and aggressively treat severe acute pain when it occurs to prevent it from transitioning into chronic pain. These new physician leaders must be capable of collaborating with other health care providers in anesthesiology, surgery, medicine, nursing, pharmacy, physical therapy, and more to establish multidisciplinary programs that add value and improve patient care in the hospital setting and beyond.

Edward R. Mariano is an anesthesiologist. He can be reached on his self-titled site, Edward R. Mariano, M.D. and on Twitter @EMARIANOMD.

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